Vol. 16, No. 3, 2007, ISSN 1854-8466.

Do we need proof? Vol. 16, No. 3, 2007 TheWrite Stuff

EMWA Executive Committee Journal insights

President: TheWrite Stuff is the official publication of the European Medical Julia Forjanic Klapproth Writers Association. It is issued 4 times a year and aims to provide Trilogy Writing & Consulting GmbH EMWA members with relevant, informative and interesting articles and Falkensteiner Strasse 77 addressing issues relating to the broad arena of medical writing. 60322 Frankfurt am Main, Germany We are open to contributions from anyone whose ideas can complement Tel.: (+49) 69 255 39511, Fax.: (+49) 69 255 39499 these aims, but opinions expressed in individual articles are those of the [email protected] authors and are not necessarily those held by EMWA as an association.

Vice President & Programme Manager: Articles or ideas should be submitted to the Editor-in-Chief (see below) Helen Baldwin or another member of the Editorial Board. SciNopsis Eden Park B, 1 rue Jean Carrara Subscriptions 83600 Fréjus, France Subscriptions are included in EMWA membership fees. By writing to Tel.: (+33) 494 83 90 20, Mobile: (+33) 662 37 91 36 Fax: (+33) 494 83 86 91 [email protected] non-members can subscribe at an annual rate of: [email protected] • €35 within Europe • €50 outside Europe Treasurer: Wendy Kingdom Instructions for contributors 1 Red House Road • TheWrite Stuff typically publishes articles of 800–2800 words East Brent, Highbridge although longer pieces or those with tables or graphics will be considered. Somerset, TA9 4RX, UK • All articles are subject to and revision by the Editorial Board. Tel: (+44) 1278 769 214, Fax: (+44) 1278 769 214 [email protected] Any changes will be discussed with the author before publication. • Submissions should include the full address of the author, including the telephone and fax numbers and email address. Suitable quotes for side Secretary: boxes can be indicated or they can be selected by the Editorial Board. Julia Cooper • Material should be submitted by email as an MS Word file using Times PAREXEL International Ltd. New Roman (or equivalent), 10 point size, and single spacing. 101-105 Oxford Road Uxbridge, Middlesex, UB8 1LZ, UK • Published articles generally include a recent photograph of the author Tel: (+44) 1895 614 403, Fax: (+44) 1895 614 323 (portrait picture, CV or passport style, min. 360 x 510 pixels). [email protected] Timelines Month Deadline Deadline Officer: distributed for receipt of articles for receipt of adverts Kari Skinningsrud March 1st January 15th February Limwric as st th Leiv Eirikssons gate 8 June 1 April 15 May st th NO-2004 Lillestrøm, Norway September 1 July 15 August Tel: (+47) 63800448, Mobile: (+47) 41338765 December 1st October 15th November [email protected] rates (in euros, €) Website Manager: Corporate Private / Freelance members only Shanida Nataraja Discovery London, Pembroke Building • Full page €1000 • Full page €200 Kensington Village • Half page €500 • Half page €100 Avonmore Road London W14 8DG, UK Behind the press Tel.: (+44) 207 173 4121, Fax.: (+44) 207 173 4001 [email protected] The Editorial Board Assistant Editor Barry Drees Education Officer: Judi Proctor Stephen de Looze Chris Priestley Accovion GmbH Richard Clark Helfmann-Park 10, Rosalie Rose D-65760 Eschborn (Frankfurt), Germany Ursula Schoenberg Phone: (+49) 6196 7709 312, Fax: : (+49) 6196 7709 114 [email protected] Alistair Reeves Karen Shashok Alison McIntosh Diana Epstein Journal Editor Susanna Dodgson Elise Langdon-Neuner Joeyn Flauaus Baxter BioScience Dianthus team Wagramer Strasse 17-19 A-1220 Vienna, Austria Tel.: (+43) 1 20100 2067 Fax.: (+43) 1 20100 525 [email protected]

EMWA Head Office Industriestrasse 31, CH-6300 Zug, Switzerland Tel: (+41) 41 720 3306, Fax: (+41) 41 720 3308 [email protected] EMWA website: www.emwa.org Cover picture Cover photograph from Nadja Meister ([email protected])

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EMWA 9th Autumn Meeting 1-3 November 2007, Basel

You are invited to the 9th Autumn EMWA meeting to be held in Basel, Switzerland from 1 to 3 November 2007 at the Ramada Plaza Basel.

The Autumn conference will again provide members the oldest university of the Swiss Confederation with further opportunity to continue with their training (from 1460), one of the best-preserved old towns in in the EMWA professional development programme. Europe and more than 30 museums. Basel is also a The workshop programme will cover a wide range of seat of the pharmaceutical industry in Europe and medical writing subjects, including advanced we will open the conference with a lecture from Prof. workshops for experienced writers looking to keep Fritz Bühler from the European Center of their knowledge up-to-date or refresh their skills. Pharmaceutical Medicine, which is located in Basel. Further details and regular updates will soon be available on the website at www.emwa.org. This promises to be an informative and educational few days for everyone. I look forward to seeing you Basel is perfectly situated for an Autumn in Basel. conference. Centrally located on the border of Switzerland, Germany and France, it is easily Julia Forjanic Klapproth accessible from all corners of the EU. The city has EMWA President

The Journal of the European Medical Writers Association 94 Vol. 16, No. 3, 2007 TheWrite Stuff

From the editor's desk:

Do we need proof?

By Elise Langdon-Neuner

Sometimes it seems that we accept things without ques- Dr Clay told a story about his father who had been the vil- tioning, whereas at other times we demand an almost lage doctor before he took over in 1916. When his father had impossibly high standard of ‘proof’. The rationale behind first qualified he had developed tuberculosis and went by the theme of this issue of TWS is to suggest that this is boat to Australia. On this voyage he had a painful soar throat rather curious—well, isn’t it? which was relieved by morphine injected into him each day by the ship’s surgeon. He became addicted to the drug and We believe what we are told by our doctor, or at least we continued to take daily doses of opiates all his life—but are expected to. Every consultation with a doctor nowa- without any apparent ill effects on his medical work. days seems to end with firm advice: “drink more water”. It does not matter what the ailment is—stomach ache, heart Of course, Western medicine is not all there is. There’s burn, erectile dysfunction—water is the universal cure. alternative medicine too, although this is generally regard- (Perhaps the bottled water industry has a thing or two to ed as suspect in Western society by reason of its lack of teach the pharma industry.) Any sign of dissent in the doc- ‘proof’. Jack Aslanian looks outside the biased terminolo- tor’s surgery and the advice is reiterated, “You know you gy used to describe alternative medicine and makes sug- must drink 2 litres of water a day, don’t you?” Despite gestions for correct terminology. And he asks an interesting extensive searching in medical journals and data bases question: “Does a particular alternative or complementary Professor Heinz Valtin, an American kidney specialist, treatment cease to be alternative and become ‘mainstream’ once it has become validated?” If they are adopted by con- found no rigorous proof to support this recommendation ventional practitioners, and demonstrated to be safe and [1]. He accepts that the human body needs 2–2.5 litres of effective then they are no longer considered alternative fluid a day but contests the belief that this must come from according to the Webscout, Joeyn Flauaus, in her introduc- water. Some of it can come from solid food. He suggests tion to some fascinating Web sites that look at alternative that people follow their customary fluid intake and thirst and complementary therapies. rather than feel guilty about reaching a target intake that has not been proved to be necessary. Other people, howev- Taking a playful look at proof in her article in this issue, er, including doctors—who are assumed to read their med- Wendy Kingdom tries to extrapolate the methods of proof ical journals—firmly believe the 2-litres-a-day myth. used in medicine to questions in everyday life. She sets out to a prospective study to prove why some of the Richard Clark introduces his article in this issue of TWS by drinking glasses she buys have a shorter time-to-breakage stating that we like to think that modern Western medicine than others. But she gets stuck on the numerous variables has a firm foundation in fact and proof. He then asks what that would need to be taken into account. Even if these constitutes proof for us and mentions a probable fact that could be corrected for, the study might not be able to prove parachutes prevent death or major trauma that can never be anything. She cites a prospective study by researchers in proved. Conversely, a few recent studies seem to have Australia which determined the rate of loss of teaspoons proved some most improbable things. A study published from their institute’s tearooms, but never actually proved last year used a double-blind trial to prove that dogs can be where the teaspoons went, which you might think would trained to sniff out bladder cancer [2]. The New England have been a most useful bit of information. Journal of Medicine recently published a perspective about As always, TWS not only contemplates the curious, but Oscar, a cat that can predict when residents of a geriatric hos- also has a lot of useful information for medical writers. pital in Rhode Island are about to die [3]. The authors of these Cathy Holding has some invaluable tips for those planning articles believe that they have proved that dogs can sniff out to branch out into medical . Geoff Hart looks at cancer and cats (at least Oscar) can predict human death. the ubiquitous human trait of assuming everybody else is Currently Western medicine accepts randomised, double- like ourselves and gives practical advice for medical writ- blind, placebo-controlled trials as the best proof for the ers who have personal or email contact with people from value of a particular drug but, returning to Richard again, different cultures. This trait was also evident when he questions whether this trial design is always the best. He Microsoft unleashed Word 2007 on a less than enthusiastic also challenges the irrational beliefs behind some doctors’ world as Karen Shashook reports. Anybody who thinks reluctance to prescribe opioids while more dangerous clients cannot be persuaded to adopt ethics guidelines will drugs are sold without prescription. My general practition- be interested in Jenny Fanstone’s article on how her com- er, Dr Clay, who had a village practice in Wiltshire (UK) pany has been successful in obtaining clients’ agreement to when I was a child, would no doubt have agreed with him. acknowledgement of medical writers.

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From the editor's desk

I don’t think we would have difficulty finding proof that come across them before and need proof that they exist, the medical journals prefer to publish positive results and that laboratory multiple animal is brought to life by our regular this can be a problem for medical writers when they are cartoonist, Michael Dawes, in his cartoon accompanying asked to advise on prospective publication venues. In Alistair’s article. Madeline Frame’s article in this issue she considers approaches that can be used to look at trial data in a differ- Finally, we are excited to introduce a new section in this ent way to find angles that might appeal to journal editors. issue of TWS especially for freelancers. We all know as well that journal editors are preoccupied This must all prove something—about TWS at least. with impact factors. But do we know how they might be manipulating these factors? In her article in this issue Diana Elise Langdon-Neuner Epstein has a bit more than ‘only an opinion’ on this topic. Editor-in-Chief [email protected] The regular columns including, Journal watch, In the book- stores, and Alistair Reeves’ Myths about English contain References: yet more practical information. In a second article Alistair 1. Valtin H. “Drink at least eight glasses of water a day.” Really? Is there scien- tific evidence for “8 x 8”? Am J Physiol Regul Integr Comp Physiol returns to the curious in his discussion about whether mul- 2002;283(5):R993-1004. tiple animals exist. This question first began to worry me 2. McCulloch M, Jezierski T, Broffman M, Hubbard A, Turner K, Janecki T. when these creatures popped up in a sentence in a preclin- Diagnostic accuracy of canine scent detection in early- and late-stage lung and breast cancers. Integr Cancer Ther. 2006;5(1):30-9. ical report: “Interstitial inflammatory infiltration was 3. Dosa DM. A Day in the Life of Oscar the Cat. N Engl J Med. recorded in multiple animals”. For those who have not 2007;357(4):328-9.

What does scientific 2 could be frightening at a time when more acceptance of responsibility and transparency is being called for in sci- language prove? ence. But number 3 is most concerning. The validity of You would think that by now everybody who gives any results remains the same regardless of whether they are thought to writing scientific text concurs with the reported in the active or passive voice. The passive voice American Medical Association’s Manual of Style, among has its place where as stated above the identity of who did many other style books, that clearly states the active voice an action is not important, e.g. the animals were killed on is preferred in scientific writing except in instances in day 5, but to suggest that the passive is of itself ‘scientific’ which the actor is of less interest than what is acted upon. places more importance on appearances than the reality Not so. I stumbled upon a page from the Gallaudet behind them. Added to this the passive can more often be University in the US which advises the use of passive ambiguous and imprecise than the active voice and the voice in scientific writing [1]. And its justification for active voice is simpler and clearer. The expression ‘blind- promoting use of the passive voiced? ing with science’ springs to mind. Ambiguity, impreci- “1. Let the facts stand on their own! sion, and complexity blind science from non-scientists 2. Removes some accusations of bias (who did it, how and scientists whose knowledge is outside the particular many did it.) field being reported on. 3. Presents an ‘air’ or feeling of logic.” The use of the active is not a newfangled idea in science. The writers of the page, who are from the departments of Science used to be reported in the active voice. According Chemistry and English, then give the following example: to Jane Smith, writing in the BMJ, it was with the rise of ‘scientific’ studies that ‘objective’ language came to be “Unscientific used [2]. She gives an example of a case report written in I did this experiment several times. Each time I got the same results. After the last time, I was convinced that I 1841 by Robert Storrs, a surgeon from Doncaster, which was right. The new bacteria must have caused all the reflects the scientific writing style of the day: “Mrs problems we found in our patients. Lowther, at twenty-two, a stout good looking woman of lymphatic temperament, was delivered, after a tedious Scientific labour, of her first child.” He describes the problems with The procedure was repeated until there was certainty her everted uterus and finally reports “About a fortnight regarding the results. The problems encountered by the ago I saw her tripping along the street quite well.” patients were caused by the bacteria.” Confidentiality prevents the use of patients’ names now- To cap it all the authors go on to give a step-by-step chart a-days in such reports but what’s wrong with the rest of on how to change active sentences into passive ones. this delightful style? Of course I know the answer. It’s not pompous, sorry I mean scientific, enough. Arguments against number 1 of the above justifications for using the passive are well presented in Matthew Stevens’ book Subteleties of Scientific Style reviewed on Elise Langdon-Neuner page 129 of this issue. He says passive sentences suggest [email protected] the work did itself and obscure the reality of science. The 1. http://depts.gallaudet.edu/englishworks/grammar/passive.html actor is not only important, he or she is essential. Number 2. Smith J. Journalology—or what editors do. BMJ 1990;301:756-9.

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Message from the President

By Julia Forjanic Klapproth

Now that the dust has settled after the conference, I want to exactly what would be involved. But what we discovered take a moment to clarify the new ideas for the Executive is that people are more willing to join a subcommittee in Committee (EC). I realized during the Annual General which they have a less formal obligation but can still pro- Meeting (AGM), and while talking to people afterwards, vide their opinions and insights, and learn something of the that not all these new ideas were sufficiently clear. So I way EMWA works. Et voilá! The idea to establish subcom- would like to use this President’s message to explain how mittees to assist the various EC officers was born. the new terms for Presidency and Vice Presidency, and how the proposed subcommittees of the EC, are meant to work. While exploring the idea of subcommittees we realized that they would reduce the burden of the EC position by provid- In recent years, there were 2 key issues for the EC: how to ing ideas, enthusiasm and support to the EC member. They find new people to fill the EC positions coming up for re- would also give people a chance to get to know what it election every 2 years, and how to provide continuity when means to be an EC member and learn about the responsi- we did. Without new people coming on to the EC it will bilities associated with particular positions. This would stagnate and ultimately cease to represent the opinions and help the people on these subcommittees make more needs of the membership. And with the system we had up to informed decisions about joining the EC. It would also now, when we managed to convince (some might say, coerce) someone to join the EC, they had no experience of how the serve as a platform for knowledge transfer to potential can- EC functions and, moreover, there was no form of knowledge didates so that they can come up to speed with a particular transfer from the outgoing to the incoming officer. position before getting started. So the question was, how can we encourage people to vol- In a nutshell, subcommittees enable us to tap into a broad- unteer and how can we improve knowledge transfer and er resource base and at the same time create a natural pool continuity within the EC? People were daunted by the fact of candidates who can volunteer to join the EC. Which that they would have no one to support them for whatever doesn’t mean that people who are not on a subcommittee responsibilities they would be taking on. Understandably, are excluded from running for a position on the EC! most people are more than a little wary of committing Everyone is always welcome. The goal is simply to create themselves to a 2-year term of office without knowing a system to improve the odds of finding new candidates.

Figure 1. Organigram of the EMWA Executive Committee and Supporting Committees

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Message from the President

So, that is the theory. But what does this mean in the real to provide ideas or support to the EC member heading the world? To try and address this I am going to describe the subcommittee. The specific activities of a given subcom- overall structure of the EC and the associated subcommit- mittee will depend on the needs of the EC position it sup- tees and I am going to answer some of the specific ques- ports and the ideas of the members contributing. For exam- tions people asked about the details of these subcommittees. ple, our Public Relations Officer is putting together a sub- committee of representatives from as many countries as Figure 1 is an organigram of the EC with the associated sub- EMWA has members in order to have local insights and committees. Each of the members of the EC has equal voting contacts when targeting a particular country. rights. All but 2 of the positions are elected, 2-year term posi- tions; the Journal Editor and the Web Editor positions are There is no set limit to the size of these subcommittees, and assigned by decision of the EC and are for undefined lengths they will vary depending on the way they interact with the of time. The Vice President, once elected, automatically EC member. It is not foreseen that any face-to-face meet- becomes President at the end of their term as Vice President, ings will be needed for these committees as all communi- making the combined posts a 4-year term altogether. cation can be managed by email and telephone. There is The decision to increase the Vice Presidency and also no time limit for participation on a subcommittee. Presidency to 2-year terms each (from previous single-year Members can stay on as long as they like and leave when- terms) was also a move to improve continuity within the ever they like. Members can also be on more than 1 sub- organisation. It is an idea that has been suggested by committee if they are so inclined. A list of all the members numerous members over the years and the EC felt the time currently on each of the subcommittees is given at had come to give it a try. Until now, the President and Vice http://www.emwa.org/Officers.html. President worked essentially independently of each other. According to our the EMWA Policies and Procedures, any The Vice President came in and had to hit the ground run- member who has attended at least 1 Annual Spring ning to organise the following year’s Spring Conference. Conference in the last 3 years is eligible to run for the posi- Rarely did the Vice President receive any guidance from tion of Treasurer, Public Relations Officer or Secretary. the President and frequently they just reinvented the wheel. However, to be eligible for the position of Vice President, By shifting full responsibility to the President for all con- it is also necessary to have served on the EC or represented ferences, the Vice President can learn the ropes while sup- EMWA in an official capacity in the last 5 years. The pur- porting the President. So again, the goal was to reduce the pose of these conditions is to ensure that someone who wish- burden of the individual by sharing the work load between es to run the organisation has demonstrated a certain amount the 2 positions, and to allow for knowledge transfer from of continued interest in EMWA and has had a chance to learn the President to the Vice President and thereby create a sus- about how EMWA runs from the inside. The problem arose tainable process that provides for continuity. in that, previously, the pool of people who fulfilled these cri- The Education Officer is elected to the EC and is simulta- teria was slim, and often consisted of people happily serving neously chairperson of the EMWA Professional other functions they did not wish to leave. Development Committee (EPDC). The Education Officer By implementing the idea of the subcommittees we are organizes the workshop programme at EMWA conferences enabling more people to actively get involved in how and represents the EPDC on the EC. All EMWA education EMWA runs. The Vice President can now be chosen from officers have previously served on the EPDC. The EPDC the EC, the EPDC and any of the subcommittees. Which itself, specified in EMWA’s policies and procedures, is cur- does not imply that by joining a subcommittee, particular- rently composed of 7 EMWA members who were invited to ly the Presidential Subcommittee, a member is automati- join the committee for a 5-year term after an application cally expected to run for Vice President. What is does mean and selection process. The EPDC develops and maintains is that the EC has a chance to observe people from a larg- the EMWA Professional Development Programme er pool who might be good candidates for the position of (EPDP), issues the Workshop Leaders Handbook, and Vice President, which should help reduce the chance of mentors new workshop leaders. The much increased work- electing someone who does not have the ideas, enthusiasm load of the EPDC—the number of workshops at the spring and commitment to do the job well. and autumn conferences has more than doubled since the EPDP was first launched—means that subcommittees of I hope that this has answered most, if not all, of your ques- the EPDC will also be established. tions about the rationale for these subcommittees and how Each of the other EC members will lead their own subcom- they are meant to function. If you have other questions, or mittee, which is developed on the initiative of the respec- would like to join a subcommittee, please feel free to con- tive EC member. The subcommittee is formed by those tact me or any other EC member. We would be happy to members who approach the EC with a desire to help out hear from you. and any other members actively solicited by the EC mem- ber. While these are to be seen as official committees of Julia Forjanic Klapproth Trilogy Writing & Consulting EMWA, they are not elected and are informal in structure Frankfurt am Main, Germany and function. The main role for subcommittee members is [email protected]

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Cross-over trials: Painful lessons

by Richard Clark

Pragmatic approach to pain trials sion criteria, and so they are not going to draw any conclu- We like to think that modern Western medicine has a firm sions (except that they cannot draw any conclusions). If foundation in fact and proof, and yet there is debate about your parent or grandparent was in severe pain or having what constitutes proof. With regard to medical writing, we very unpleasant side effects while receiving an opioid, accept that the burden of proof is addressed in the form of would you tell the clinician not to try switching them to clinical trials. The randomised double-blind placebo-con- another opioid because the review didn’t draw a trolled trial is generally accepted as the best proof for a par- conclusion on the subject? Of course not! ticular drug, but is it always the best trial design? Some years ago I had the onerous duty of trying to get the Evidence-based medicine protagonists results of a ‘pragmatic’ trial accepted in the British Medical wanted for parachute trials Journal. For reasons I won’t go into, a placebo-controlled, This puts me in mind of the (not entirely serious) call for double-blind trial was not appropriate given that the two randomised double-blind trials of parachutes [4]: The analgesics had different routes of administration such that authors wanted to determine if parachutes were effective in a ‘dummy’ treatment would soon be unblinded. As many preventing death or major trauma “related to a gravitation- patients were suffering from severe chronic pain, a place- al challenge” by conducting a of ran- bo group wasn’t ethical. Furthermore, the powerful anal- domised controlled trials. They were unable to identify any gesic effect of placebo in pain management is still not randomised controlled trials of parachute intervention. understood. We argued that comparing a new medication Thus, they concluded that: with the normal first-line treatment and using a cross-over “As with many interventions intended to prevent ill health, trial design was the best approach, and eventually the man- the effectiveness of parachutes has not been subjected to uscript was accepted and published [1]. Notwithstanding rigorous evaluation by using randomised controlled trials. these arguments, the editorial (written by an expert in evi- Advocates of evidence-based medicine have criticised the dence-based medicine) was particularly scathing about the adoption of interventions evaluated by using only observa- lack of double blinding [2]. Neither did he like patient pref- tional data. We think that everyone might benefit if the erence as one of the outcome measures. As pain is subjec- most radical protagonists of evidence-based medicine tive, patient satisfaction with their analgesic, or their pref- organised and participated in a double-blind, randomised, erence for one analgesic over another, deserves special placebo-controlled, cross-over trial of the parachute.” emphasis in pain management. Irrational beliefs Cochrane reviewers have their say To take the other side of the argument, we sometimes tend An audit of 43 major clinical guidelines with potential cov- to have some fairly irrational beliefs, even when there is erage of opioid-induced constipation formed part of a overwhelming scientific evidence to oppose this irrational- poster I was writing recently. Most of these guidelines gave ity. Many doctors are afraid of prescribing opioids because some sort of advice on the management of this condition, of a perceived danger that proper medicinal use of these but a notable exception was the Cochrane Review on opi- analgesics leads to a danger of physical addiction. In fact, oid switching which gave no firm advice due to a lack of this is very rare. On the other hand, many more dangerous randomised controlled trials: drugs are sold without prescription. In the UK alone, non- “Opioid switching is the term given to the clinical practice steroidal anti-inflammatory drugs cause about 2000 deaths of substituting one strong opioid with another, in an per year due to gastrointestinal damage that they can cause attempt to achieve a better balance between pain relief and [5]. In the US this figure reaches 16,500 deaths per year side effects. This is an established clinical practice for [6]. patients with cancer pain, but the evidence is based on case The reaction to the introduction of the measles, mumps and reports and uncontrolled studies, and no randomised trials rubella (MMR) triple vaccine is another example of irra- met the inclusion criteria for this review [my italics]”[3]. tionality. The mass of evidence shows the safety of this for- This is so typical of the Cochrane reviewers. It takes 30 mulation, but many people did not want their children vac- pages of text to tell us that not one study met their inclu- cinated with it, instead preferring single vaccines (despite

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Cross-over trials: Painful lessons the lack of any evidence that single vaccines are any safer). is a little-known branch of Chinese medicine that dates Many didn’t vaccinate their children with any of these from about 1700 BC that includes massage of soft tissues component vaccines in any form. One study in 12 children (muscles, ligaments and tendons), accupressure techniques had alleged a potential link between autism and the MMR and musculoskeletal/ligament manipulation. No doubt the vaccine [7], and together with media hype and the per- Cochrane reviewers would not be pleased. It would be ceived rise in incidence of autism, this led to low levels of great to have a randomised cross-over trial of Tui Na with MMR vaccination in the UK. Though the weight of evi- ‘usual care’, but I’m not going to wait for that. dence is skewed dramatically in favour of vaccination, many parents might feel worse if they actively did some- Richard Clark thing causing their child to be ill (i.e. vaccination followed Freelance Medical Writer by autism) rather than being passive (no vaccination and Vitruvian Medical Writing Ltd., Oxford, UK then the child gets measles, mumps or rubella). This is [email protected] understandable but not very logical. Interestingly, even a References: 1. Allan L, Hays H, Jensen NH et al. Randomised crossover trial of transdermal Cochrane Review concluded that “There was no credible fentanyl and sustained-release oral morphine for treating chronic non-cancer evidence behind claims of harm from the MMR vaccina- pain. BMJ 2001; 322: 1154–8. tion”, so you know that the evidence in favour of MMR has 2. McQuay H. Opioids in chronic non-malignant pain. BMJ 2001; 322: 1134–5. 3. Quigley C. Opioid switching to improve pain relief and drug tolerability. to be overwhelming! Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004847. DOI: 10.1002/14651858.CD004847. 4. Smith GCS, Pell JP. Hazardous journey. Parachute use to prevent death and A logical approach to causality? major trauma related to gravitational challenge: systematic review of ran- We need to take a more logical approach to causality. The domised controlled trials. BMJ 2003;327:1459-61. causal criteria set by Sir Austin Bradford-Hill are very use- 5. Tramer M, Moore R, Reynolds D et al. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic ful in this respect [8]. These are: (1) strength of association, NSAID use. Pain 2000; 85: 169–82. (2) consistency of observation, (3) specificity of associa- 6. Singh G. Recent considerations in non-steroidal anti-inflammatory drug gas- tropathy. Am J Med 1998; 105: S1–S38. tion, (4) temporality of the relationship, (5) existence of a 7. Wakefield AJ, Murch SH, Anthony A et al. Ileal-lymphoid-nodular hyperpla- biological gradient, (6) plausibility of causative relation- sia, non-specific colitis, and pervasive developmental disorder in children. 1998; 351: 637–41. ship, (7) coherence of causative relationship with existing 8. Bradford-Hill A. The environment and disease: association or causation? understanding, (8) experimental demonstration of cause Proceed Roy Soc Medicine 1965; 58: 295–300. and effect by manipulation of suspected cause and (9) analogy to an existing recognised cause. However, I’m assured that it is not as simple as this (though it seems com- plicated enough already!). Bradford-Hill never used the term ‘criteria’ and he explicitly stated that he did not believe any hard-and-fast rules of evidence could be laid down, emphasising that his nine “viewpoints” were neither necessary nor sufficient for causation. Nevertheless, as a Queuing strategy non-statistician myself, these criteria seem pretty useful, for medical writers even if they just form a framework for discussing evidence regarding a potential causative relationship. To come back In that awkward pause in a buffet queue, after you have to the MMR example, parents are worried that there is an been asked what you do for a living and have replied association between this multivalent vaccine and autism ‘medical writer’, you might consider filling the silence 1 based on temporality (Bradford-Hill criterion number 4). with a few facts from Word Trivia as follows: This is clearly just one facet of the logical approach to I am (which by-the-way is the shortest complete sen- causality and is not enough on its own, particularly in small tence in the English language) a medical writer. Did you numbers of vaccinated children. know that ‘hillypilly’ is one of the two longest words in English consisting only of letters with ascenders, Tui Na descenders and dots in lower case, ‘asthma’ begins and Western medicine does not have all the answers. So, many ends with a vowel but has no other vowels in between, people (myself included) have used ‘alternative’ medicines ‘abstemious’ has five vowels in order, the plural of or therapies—in the absence of scientific proof—in prefer- ‘mouse’, the rodent, is ’mice’ and the plural of a comput- ence to mainstream medical treatments. Why is that? The er ‘mouse’ is ‘mouses’, the word ‘stifle’ is an anagram of usual advice about chronic back pain has changed from ‘lie ‘itself’, the longest words that are reverse images of very still on a hard surface and don’t move’ to ‘take each other are ‘stressed’ and ‘desserts’—at this point painkillers and perform your normal daily activities’. I’d you might find that your stressed audience has made for had a bad back for quite a while, and neither of these the desserts leaving your field free for the starters. approaches worked very well. Chiropractic treatment helped a bit, but recently I’ve tried the exotic-sounding Tui Na, which has been remarkably effective. Essentially, this 1. http://users.tinyonline.co.uk/gswithenbank/wordtriv.htm

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Reflections on terminology: Not ‘alternative’ medicine but integrative medicine

by Jack Aslanian

What catchall term should we medical writers and editors liminal. Some even claim that the proper name given a favor and promote for referring to the totality of approach- child has effects (sonic, perhaps even occult) on the devel- es to wellness and healing that include both the allopathic opment of his or her personality. More obviously, if parents (‘orthodox,’ ‘Western,’ or ‘mainstream’ as some refer to were to name a daughter Horatio, or a son Judas, to use them) reactive and interventionist medical discipline as rather exaggerated examples, that naming not only will well as that other group of diverse, internationally or reflect the characters of the parents, it will also determine regionally recognized diagnostic and therapeutic approach- what peer and societal influences and experiences the child es (often not much less reactive in nature) that the public will have growing up and in adult life. tends to regard (because that is the way they are presented In a literature survey (which for the purposes of this essay to it) as ‘alternatives’ falling outside ‘established’ medi- I might have limited to a mere skimming of forewords and cine? A quick review of the book and periodical literature introductions) I came across the following terms appended relevant to the topic reveals many different, often impre- to and qualifying ‘medicine’—there may be others, but cise, laden, nuanced, even divisive terms used to refer to these are the ones most frequently used to refer to non-allo- the second group. The overall impression is one of arbi- pathic medicine: alternative, unorthodox, unconventional, trariness in the naming of the body of non-allopathic ways, traditional, fringe, complementary, cross-cultural, as if the abundance and diversity of names are the progeny mind/body, natural, all used to refer to the non-allopathic of hasty responses to come to terms with its presence and field1. Keeping these terms close company are two others, growth (inexorable and threatening to some establishmen- holistic medicine and integrative medicine. Perhaps the tarians) in modern Western society. Those with the time dismissals that follow of most of the contending terms will and inclination to do it can apply content analysis to gauge generate debate, and also suggestions for other—and, one the current usages of the various terms, or they can focus hopes, unifying and precisely indicative—alternative terms on historical research to ascertain when a particular expres- for integrative medicine. My purpose is not to describe or sion was first used, in what context, and with what mean- champion any particular medical philosophy or method. I ing. Neither the currency of a name nor its biography, how- would like to suggest that some terms are more appropriate ever, gives it legitimacy. In this essay I analyze many of the than others for referring to them all as a group. Most of the diverse names commonly, and often interchangeably, used contending terms I have listed above have this in common: to refer to non-allopathic medicine, and I argue that almost at best they sustain a duality. Some do worse and reinforce all of them lack the needed precision or neutrality to be antagonism. allowed currency in professional or public discourse. My preferred term is ‘integrative medicine;’ and after giving Fringe medicine—Although presently not in very common reasons for dismissing its contenders, I will finish by pro- use, this coinage is found in professional, quasi-profession- posing that that is the most unifying and precisely indica- al, and lay literature. It is one indicator of the conceit and tive, and neutral, term to use in equanimous discourse. bigotry that could enter social and political discussions of various healing arts. On a practical and basic it should not matter what a corpus of healing practices is called. A name is a symbol Unorthodox/unconventional medicine—In the first of the and a tool for referring to the designee. The average person two coinages, the disdain and dismissal implicit in ‘fringe does not care whether a therapeutic approach is called allo- medicine’ is given an authoritarian aspect. The second also is judgmental, and depends on by whom and how the ‘con- pathic or conventional or if it is called holistic or comple- ventional’ variant is defined. It is safe to assume that not mentary. He or she is interested only in being cured or stay- one of the three expressions originated in the camps of ing well. The practitioner, on the other hand, should be per- believers and parishioners of non-allopathic disciplines. suaded by efficacy rather than by a name or hierarchic alle- giances. Still, we know that words are not tools simply; Traditional medicine—As used in this context the adjective they carry overtones and meanings, sometimes only sub- refers mainly to ancient and long-established medical cus-

1 A search for those terms in Dorland’s Medical Dictionary (30th Edition, 2003) revealed only ‘holistic’ defined as a main entry or under ‘health’ or ‘medicine.’ Complementary and alternative medicine were cited and defined together under the main entry of ‘medicine’ as: “… alternative [italics in the original], that is, existing as a body separate from and as replacement for conventional Western medicine, or complementary [ditto], that is, used in addition to conventional Western practice.” [1]

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Reflections on terminology... toms rooted in diverse cultures. Although this too is a rela- lished [sic] allopathic medicine. Too often it is found writ- tive term, it has little negative connotation or hubris. Yet, ten as ‘mind/body medicine.’ Occasionally, but with the implied referential precision of this term is one reason increasing fashionableness, a nomenclatural trilogy is it should not qualify as a choice for an all-encompassing insinuated in the discourse in the form of ‘mind/body/spir- alternative moniker for integrative medicine—or even it medicine2.’ Using mind-body medicine to refer to all of exclusively for the domain of non-allopathic medicine. non-allopathic medicine is not much different from using Some of the methods in the realm of integrative medi- ‘neuroendocrinology’ to refer to all of psychosomatic med- cine—such as biofeedback or any of the various elec- icine. And leaving hierarchic distinctions aside, to precise- trotherapies—are not all that ‘traditional.’ The basis of a ly reflect the interdependent relationship that it aspires to lesser objection is that ‘traditional’ implies temporality imply, the term should always be written with a dash, as within a particular context. Because the problem to be ‘mind-body medicine,’ not with a slash—for all would solved here is finding a mot juste for that context, it follows agree that it is not a matter of either/or but of teamwork, that the adjective cannot be used in the naming of the con- interconnectedness, and reciprocity. text itself. Finally, institutions create their own traditions Complementary/adjunctive medicine—‘Complementary (after how many generations?). In high-powered, estab- medicine’ is fairly free of the overtones of primacy and lished academic settings the ‘traditional’ comprises the superiority that, one could argue, ‘adjunctive medicine’ philosophies and methods of such institutions. And in fact, seems to have. Still, even if it were to be construed to imply some Westerners writing in the field (e.g. Stedman’s an easy coexistence with its rival, and perhaps even a Medical Dictionary, 28th Edition, 2006, page 1169) have coequality, complementary medicine does feed the concep- used ‘traditional’ to designate not the ancient and ethnic tual divide—the allopathic/‘established’/‘conventional’ on (which in this context now are ‘non-traditional’) but the one side and, on the other, the others, variously named medical methods nurtured by Western scientific/academic approaches collectively considered complementary to the institutions—thus further confounding the use of the adjec- former. Still, those who have coined ‘complementary med- tive in this context. icine’ and given it an office—as in ‘complementary and 3 Cross-cultural medicine—I came across one tentative alternative medicine’ (CAM) — should receive credit for attempt to wield this term into usage as a catchall referent implicitly acknowledging that allopathic medicine has its to non-allopathic medicine. It could be an appropriate limitations. name for historical, anthropological, or sociological Alternative medicine—Currently, this seems to be the term approaches to the study of medical practices for the pur- most common in both professional and lay usage—in titles pose of establishing roots and geographic or temporal trans- of books, , and articles; and as noted above, it ference; it is not appropriate for designating established or has been rather legitimized by combining it with ‘comple- developing practices. Knowing the cultural connections of mentary’ in naming an institution. Perhaps the adjective is a healing method does not change its usage. (And it should popular because it rolls around the tongue more smoothly not—politically correct and enthusiasm for fusion should than ‘integrative;’ or perhaps because in the hierarchy of not be the primary patrons of medical practices.) words it is more pedestrian (therefore less challenging also Natural or naturopathic medicine—Each of these two mentally) than either ‘integrative’ or ‘complementary.’ terms are used loosely as nominal umbrellas for the non- Perhaps democracy requires that there be choices. Or per- allopathic approaches. But each is delimiting: Naturopathy haps its professional usage gets a boost by the subtle shift- ing (implied) of the final decision to the chooser, increas- is a subset, one among several non-allopathic approach- ingly the empowered patient (thus satisfying the need of es—and one that by definition would exclude homeopathy, the patient to have a say in his/her healing and, in these for example. Furthermore, it is fair to ask: “Why may days of patient rights, litigiousness, and mistrusted medical acupuncture be considered ‘natural’ and the application of profession, the wishes of the practitioner to reduce exposure a #11 scalpel to a boil not?” Also, ‘nature’ may have decep- and dilute his/her accountability)4. My main objection to tive and misleading appeal to lay people. this term, as opposed to holistic or integrative medicine, is Mind-body medicine—This is a proper (and welcome) that it is commonly used to refer not to the totality of medi- term for referring to a particular conception of the human cal theories, knowledge, and practices but only to those organism and an approach to the diagnosis and treatment of grouped under the non-allopathic banner: If allopathic its imbalances. It, however, is too often used as a catchall treatments do not work let the patient resort to the alterna- term, to refer to whatever is outside the domain of estab- tive [the provider’s side]; or, if I mistrust the white coat or >>>

2 The perspective from this specific conceptual vantage point is appealing, and the spirit has an important role in maintaining wellness. However, the tri-brid term [sic], whether hyphenated or separated by slashes, implies three coequal compartments and a separation between ‘mind’ and ‘spirit’—and a distinction between the two. Without denying the existence of spirit, current knowledge would support the notion that we are conscious of some things called spirit and spirituality, and can resort to them, only because mind exists as a process. 3 As in National Center for Complementary and Alternative Medicine, under the auspices of NIH. 4 When an adjuster [sic] in an insurance company denies coverage for a referral or procedure, is that person practicing allopathic judgment or one rooted in alternative medicine?

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>>> Reflections on terminology... don’t want to take prescription drugs [the patient’s side], let Finally, the case for integrative medicine: it would encom- me try alternative medicine. Therefore, this term continues pass non-allopathic practices as well as allopathy to refer to to maintain a divide between two territories, which is at an integrationist medicine that brings together the best least fuzzy5. Still, if ‘alternative’ were to be used as a noun from various medical modalities7. Wellness and healing rather than as an adjective, ‘alternative medicine’ could should not depend on specific and exclusionary outlooks. awkwardly serve as a coinage that stands for a discipline In medical practice, it is no longer a question of, “If you’re that allows picking and choosing from everything that all not in step with us, then you’re in the fringe.” care providers know to offer, regardless of their trade titles. Nomenclature should reflect more than the competitive Better yet, it could be applied similarly but used in the plu- coexistence of disciplines; it should mirror concurrence ral, as ‘alternative medicines.’ Other questions that the con- based on an honest acknowledgement of facts. It should cept of alternative medicine raises are these: is a particular reflect the emerging openness and the gradual crumbling of treatment alternative or complementary as long as it has a face-off. There is sufficient experimental evidence (in not been validated by scientific methods? And once thus controlled studies, the validator of scientific knowledge) validated: does it cease to remain alternative and become and experience, and the patients’ subjective reports of ben- mainstream? In a related vein: in any of the coinages dis- efit, to allow to confidently state that many, many of the cussed here, but especially this one, should ‘medicine’ healing practices that were once dismissed with skepti- refer to one, a single, specific therapy or intervention? To a cism, often also with insults and derisiveness, do work— medical approach or outlook—homeopathy, for example? acupuncture, or example, relaxation techniques, or some To a warehouse of disciplines? To anything that has to do herbals. If relaxation and imagery exercises done before with wellness and healing? The preceding set of questions surgery reduce postoperative pain, they should not be con- might be considered pedantic, but I am raising them to sidered outlying modalities. Not only do they work, they illustrate the imprecision of terminology. sometimes work where surgery or pharmaceuticals may not work at all, or may work but accompanied with the In medical practice, the adjective ‘alternative’ poses other potential of side effects and complications. In addition, conceptual problems. Are there any true alternatives to sur- there are reports that in certain societies the so-called alter- gical intervention for a condition such as tension pneumoth- native medical approaches attract more of the public than orax? Would, or should, any physician or patient in his/her does allopathic medicine. Public dependence on holistic right mind delay treatment to determine if there are? On the modalities is up, and rising; insurance companies even other hand, if a chronic pain condition could be alleviated cover the cost of some of them. The best medical practice by chiropractic or relaxation techniques, for example, is is one that integrates various theories and proven approach- pharmacotherapy really an alternative for its treatment? es while being open to new knowledge about the effective- Holistic medicine—Its sonorous qualities, its allusions to ness of approaches and practices that, without doubt, will and invocations of unity of function (but also to teamwork continue emerging. Such openness and sense of mutuality between diverse medical disciplines), and the very idea of will banish the use of loaded or fragmenting terminology. holism perhaps make this term the ideal candidate for The elephant is an organism and the most faithful view of adoption. Yet, it is not as popular as ‘alternative medicine.’ it is integrative. The reason for this may be the slight historic disadvantage it has: in certain societies it invokes images of ‘flower chil- Jack Aslanian dren,’ ‘new age,’ ‘dropouts,’ ‘hippies,’ and counter-culture, Freelance medical editing among other associations similarly off-putting (at least in Oakland, California, USA the staid and sanctified professional context of healing [email protected] arts). That little bit of loaded imagery, however, can be dis- Select references: counted, especially because some of the social that, 1. Dorland’s Illustrated Medical Dictionary. 30th edition. Philadelphia: WB Company, 2003. as hangers on, originators or adherents of various healing 2. Cassileth BR. The Alternative Medicine Handbook. New York: WW Norton & practices, or as hopeful supplicants, did help holistic health Co., 1998. 3. Fontanarosa PB, editor. Alternative Medicine: An Objective Assessment. gain acceptance are nearly defunct and others have been Chicago, AMA: 2000. assimilated and lost the threatening reactionary vitality 4. The Burton Goldberg Group, compiler. Alternative Medicine: The Definitive they had. ‘Holistic medicine’ should remain a reliable Guide. Puyallup, Washington: Future Medicine Publishing Inc., 1993. 5. Pelletier KR. The Best Alternative Medicine. New York: Simon & Schuster, 6 alternative to the other currently very apt term . 2000.

5 One book on the topic has the following view of alternative medicine under the heading of ‘An Important Message’: “…Because the methods described are, by definition, alternative methods [bold face in original], many of them have not been investigated and/or approved by any government or regulatory agency.… Accordingly, …should not be substitut- ed for the advice and treatment of a …licensed professional, but rather should be used in conjunction with professional care.” [3] The responses that such cautionary character- ization deserves are self-evident. Among them: There appears to be confusion between ‘adjunctive medicine’ and ‘alternative medicine.’ 6 It should be used at least to designate the entire field of non-allopathic medicine. 7 And if chauvinistic exponents of allopathy do not subscribe to this melding, integrative medicine would still be a better term than alternative medicine in that it is more instruc- tive to refer to a stance and process than to a territory the other side of a fuzzy division.

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Breaking news

by Wendy Kingdom

the first place. It would be necessary to weigh up the cost- It is my observation that drinking glasses of the same type benefit ratio of determining quality as opposed to cost. do not break at the same rate. Put another way, my kitchen Failure to do so could jeopardise the whole experiment. cupboard contains an odd assortment of glasses that were once part of larger sets. The single items remaining are the If one wished to study the phenomenon of the rate of glass- ones that are of particular interest. One might think that if breaking in detail, one would need to conduct a prospective one were to purchase a set of four glasses and three of them survival study. Planning such a study is rather complicated were broken after 9 months, then the fourth glass would be because there are so many factors that can influence the broken within one year. Yet there are odd glasses in the cup- probability of a glass being broken, for example, frequen- board that have outlived their counterparts many times over. cy of use. There would have to be a system of rotating the glasses, or only using the test glasses when the whole set This observation was particularly acute recently when I will be used at the same time. bought a set of four drinking glasses from the supermarket. Three of these glasses were broken in a very short time, which I put down to the poor quality of the glass. However, the fourth glass wasn’t going to give up so easily and kept going for months until I decided to make it the focal point of this article, then it broke (Fig. 1). The quality of the glass cannot provide an explanation for the rate at which the glasses were broken. The glasses that I mentioned in the paragraph above cost only £5 (about €7.3) for a set of four. I bought another set of four glasses of a different design but for the same cost from the same Figure 1 Figure 2 supermarket, and these glasses appear to be indestructible. The presence or absence of children in the household is Well, I have no doubt that I can break them if I choose to likely to have an influence on the longevity of drinking but I mean that none of these glasses have broken during glasses, which suggests that the study should be conducted everyday use over a period of about 6 months. Therefore, only in households that lack the joys of the presence of lit- the cost of the glasses cannot be a significant factor in the tle people. However, as we all know, clumsiness is not a breakability rate. characteristic exclusive to children. Therefore, it might be Of course, the quality of the glass is not necessarily related necessary to apply an appropriate test—a Butter-Fingers to the cost. Apparently, one way to evaluate the quality of scale—to exclude any households in which one or more of glass is to look at it end-on (Fig. 2) and see how green it the inhabitants score above average in this test. This opens looks: the darker the green, the poorer the quality of the up a whole new area of study as there doesn’t appear to be glass. So, unless one were to use a colorimeter of some a suitable validated rating scale available in the literature, so this would have to be devised and tested. description (presumably at great expense) a colour chart would be needed and the glasses graded on a categorical Then, it would be necessary to examine the effect of wash- scale. However, the colour test falls down when the glass- ing the glasses by hand or putting them in a dishwasher. es are of different shapes. Can you reasonably compare a One can’t make assumptions about which method is more straight-sided tumbler with a long-stemmed wine glass? I likely to result in a glass being broken. Dishwashers ruin don’t think that you can. glasses by turning them cloudy but the glasses do not usu- ally get broken. Better quality glasses are more likely to be Another way to find out the quality of a glass is to flick the hand washed than put in a dishwasher to preserve their rim with a finger nail; the clearer the ring, the better the appearance so we’re back to the argument above about the quality of the glass. One could devise a ‘ping’ scale such as quality of the glass, but now there is the confounding fac- 0 = dull thud, 1 = slight ring, 2 = moderate ring, 3 = quite tor of the method of washing. nice ring, and 4 = rings like a bell. One might have to resort What about the volatility of household relationships? Some to employing an expert, which could be very costly and not people enjoy a good argument and they throw crockery at very sensible if the glasses only cost £5 for a set of four in >>>

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>>> Breaking news each other—so I’m told. Then there’s how much you like days). The principal findings were that the half-life of a the glasses. If you buy some that will do for now but you teaspoon in the institute was 81 days, which translates into don’t particularly like them, you can be sure that the ones a rate of loss of 2.58 teaspoons per person per 100 teaspoon that you bought because they were nice will be broken years. However, although these researchers were able to much more quickly than the ones that you don’t like. How determine the rate of loss of the teaspoons, they were on earth could you test for that? unable fully to find out where they went and resorted to Overall, therefore, just thinking about the glass-breaking speculation on the existence of a planet in the cosmos that puzzle by myself I have identified the cost, the quality of is entirely given over to teaspoon life-forms. the glass, frequency of use, method of washing (and I for- Having considered all of the above, none of the factors that got to mention the wearing, or otherwise, of rubber I have considered would explain why in any set of four gloves), clumsiness of the user, temper threshold, and like- glasses, three of them will break in a shorter time than the ability factor as possible variables that would have to be fourth glass. The only thing of which I can be certain is that considered in a prospective study. If one were to set up a we have too many odd glasses and it’s time that we ‘recy- research team to study this observation in detail, who cled’ some. knows how many other variables might be identified that would contribute to the joys and complications of proving the scientific point. Wendy Kingdom Wendy Kingdom Limited, Somerset, UK I am not alone in my pondering and quest for extending the [email protected] gambit of the prospective study to things that might other- Reference: wise just slip by us when we are not looking. Academic 1. Lim MSC, Hellard ME, Aitken CK. The case of the disappearing teaspoons: researchers in Australia have tried to find out what happens longitudinal cohort study of the displacement of teaspoons in an Australian to the teaspoons in their research institute [1]. They con- research institute. BMJ 2005; 331: 1498-500. ducted a prospective study in which the eight tearooms in the institute were populated with a known number of tea- Wendy Kingdom is Treasurer of EMWA and joint owner of some spoons. The whereabouts of the teaspoons were then mon- very odd crockery. itored over a period of 5 months (a total of 5668 teaspoon

companies and drug regulatory authorities in which drug Full access to data on safety companies would give full access to all and effectiveness of drugs? protocols and to the periodic safety update reports. It also proposes that patients' needs and not industry patents An editorial in the BMJ on direct to consumer advertising should be the focus of regulatory bodies. of drugs in Europe suggests a partnership between drug Magrini N and Font M. Direct to consumer advertising of drugs in Europe. BMJ 2007;335:526

Getting your job title right I have had considerable experience in co-ordination, both at my work running a small private company, and This is a job announcement published in The Guardian. in my leisure time, where I have been involved in a NEIGHBOURHOODS & REGENERATION range of organisations, from scouting to amateur dra- ANTI-SOCIAL BEHAVIOUR COORDINATOR matics. SAFER COMMUNITIES SERVICES I have had less experience in anti-social behaviour, HACKNEY COMMUNITY SAFETY TEAM but feel I could learn quickly. Activities I would pro-

Society Guardian, August 29, 2007, p19 mote would include providing open air meeting places for young people, encouraging the use of amplifica- Tim Albert, who for many years has written articles and tion in dense housing areas, and running courses in books, and run courses on writing scientific papers, graffiti spraying. thought this might be an opportunity for a change in This is a very worthwhile project and I look forward career direction and applied for the post. This is his letter to causing distress to the residents of Hackney. I of application. assume that the funding is coming from a lottery fund- ed arts project and I would be grateful if you could Dear Response Handling Consultants confirm this. ANTI SOCIAL BEHAVIOUR CO-ORDINATOR I also look forward to receiving full details. I was very interested to see this advertisement in yes- Yours sincerely terday's Guardian and feel that I am partic- ularly qualified for this post. Tim Albert

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Making the most of clinical trials publication

by Madeline Frame

Having worked in the pharmaceutical industry for many in New England Journal of Medicine and feel that if they years, I have witnessed the increasing complexity of the submit a sufficient number of papers, eventually one will clinical trial documentation required to register and sup- be accepted! In essence, a medical writer, who is emotion- port new drugs. This has increased the cost and amount of ally detached from the research, can have a valuable role in work involved in collecting the extensive data, but has pre- moderating the choice of journal. sented opportunities in terms of accumulating large amounts of peripheral clinical data that can be explored Publication of secondary analyses and published to extend a drug’s profile and possibly lead Although authors are sometimes criticised for ‘salami slic- to new indications for its use. ing’ their data, there is value in publishing different aspects of a study in different papers, allowing extra detail and ‘in Publication planning for primary data depth’ discussion. When study protocols are initiated, it is usual even at that early stage to make a preliminary publication plan. This This may involve sending them to specialised journals out- will involve deciding who the principal authors will be and side the normal realm of the drug, for example pathology the main publication packages likely to be available from journals for histological findings. Sometimes publications the data collected. Generally, the aim is to present the pri- fit well ‘back to back’ in a journal and can be submitted to mary data at major congresses (i.e. the most important and the journal as a pair. In that instance, usually the full meth- influential ones) as soon as it is available, before full pub- ods only need to appear in one of the papers, and can be lication, and these congresses will be identified in relation cross-referenced in the other. This generally makes the to the study end date and availability of data. It is impor- results more digestible than having all results in one paper. tant to be aware of the abstract deadline and to allow time There is also merit in submitting abstracts on data subsets, for review and approval of abstracts before submission. If where there may be insufficient data for a full paper, but an there is a tight timeframe between completion of data important point has been addressed in the analysis. analysis and abstract submission deadline, it is helpful to Abstracts also serve to keep the drug in profile at congress- have the abstract drafted in a skeleton format, ready to es when it is no longer a new product. insert the data. With regard to full publication of the primary data, ideally Publication of safety data it should be submitted to a journal selected as the highest In most current clinical studies, a significant amount of ranking one that is likely to accept the paper. By careful safety data is collected and frequently both serious and targeting of the most suitable (not necessarily specialist) non-serious adverse events are presented in manuscripts. journals, a lot of time can be saved. Sometimes it is worth As it is now much more difficult to introduce new contacting the editorial department of a journal to inquire compounds onto the market, the prospect of showing fewer whether they may be interested in the results of a particu- adverse events with one therapy than another can be con- lar study. Journals like Lancet like to be involved with cut- sidered as a treatment advantage for competing ‘marketed’ ting edge research in medicine, so if your study is genuine- products. In relation to drugs that have been well tested, ly ground-breaking, it is worth a shot. If manuscripts are there is a case for presenting their long-term safety profile sent to top ranking journals without careful consideration and this involves trawling lots of studies where ‘normal’ of their true merit and contribution to the field, they will clinical chemistry has only been touched upon in primary frequently be rejected, and each process of revision and re- publications. This can be especially important in relation submission to an alternative journal is time-consuming and, to, for example, safe use of drugs during pregnancy. for the pharmaceutical company, time lost in profiling a new drug or indication. That advice probably comes over Getting around publication bias: Choosing in a patronising way and may seem like common sense, but appealing angles it is not unusual to hear colleagues or study steering com- The pharmaceutical industry as well as practising physi- mittees going through their list of rejections from various cians or scientists are often criticised for publishing only journals and not to be surprised, given their over-inflated their positive results, leading to publication bias and an expectations. I think some people want to have their name unbalanced view of their research. On the other side of the >>>

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>>> Making the most of clinical trials publication... coin, however, high profile journals are not so interested in has been established. In my personal experience, there is studies that, for example, show a small difference between often a huge unmet need in paediatrics for good therapies, two drugs that is unlikely to have a huge influence on ther- as so many drugs are not indicated for children owing to apeutic practice. This is not because the data are inadequate lack of data. Paediatric studies are inherently difficult to in any way, but because they are not exciting or eye-catch- perform, but the rewards from publishing the data and ing. extending a drug’s indication into paediatrics can be con- I was once involved in writing an article about two antihy- siderable. pertensive drugs and the study had been well-performed in Conclusion a multi-racial population. The results were good but not Freelance medical writers working outside the pharmaceu- particularly new, and the paper was rejected initially for tical industry may not have the authority to influence deci- that reason. Consequently, we decided to take a different sions on which publications can be derived from a study tack and looked at the influence of ethnicity on drug responsiveness, as it was already recognised that there was and where they should be published, but a thorough read- a higher incidence of hypertension in the black population. ing of a clinical report may prompt them to give some ideas Taking this view of the data, we found some additional as to how the best can be made of the results. It is always interesting findings, and whilst the main results were still worth looking at opportunities in the data when the primary presented, the additional findings provided the spice. The data are being written up, as this can have an influence on manuscript was immediately accepted by a mainline journal! journal selection for future publications. Nowadays, it is more difficult to perform post-hoc or Madeline Frame unplanned statistical analyses, unless they are predefined AstraZeneca R&D in the protocol. Ideally the protocol should cite many sec- Luton, UK ondary variables that may be explored. Thus as much data [email protected] as possible can be gleaned without altering the statistical design or schedule. In a recent article in the BMJ (2007;334:1341) on a clini- Key points in publication planning cal trials conference, Michael Day reported that • When study protocols are initiated, it is usual researchers were criticised for not analysing their data in even at that early stage to make a preliminary sufficient depth to make real value judgments on the best publication plan. treatment for patients. In the same article, clinical trials are • Large amounts of peripheral clinical data criticised for focussing on highly selected groups of collected during clinical trials can be explored patients who are not necessarily representative of the gen- and published to extend a drug’s profile and eral population, and for using treatments that may be diffi- possibly lead to new indications for its use. cult to replicate in normal clinical settings. These criti- • The aim is to present the primary data at major cisms are not so easy for the pharmaceutical industry to congresses as soon as it is available, prior to resolve, however, as the regulatory safety demands are full publication in a high-ranking journal. It is such that testing of new drugs is restricted to carefully important to be aware of the abstract deadline selected groups who do not have other major diseases such and to allow time for review and approval of as cardiovascular disease or liver/kidney impairment. abstracts prior to submission. Children under 18 years and pregnant women are usually • If manuscripts are sent to top ranking journals excluded too. These restrictions generally result in a long without careful consideration of their true merit programme of studies, with wider patient groups only and contribution to the field, they will being tested once a substantial safety base for the new drug frequently be rejected, and each process of revision and re-submission to an alternative journal is time-consuming. • There is value in publishing different aspects of a study in different papers, allowing extra detail and ‘in depth’ discussion, or as short abstracts, Internet interest if few data are available pertaining to a specific point. There are 1.1 billion Internet uses: 398.7 million in Asia, • If results are good, but not particularly new, it 314.8 in Europe and only 233.3 million in North may be valuable to take a different slant on the America. 5.5. million people are apparently still waiting data that give originality and interest for to be connected. journals. : Bryne C. Google evangelist unveils his Web vision. • The medical writer can play a valuable role in The Independent 27 August 2007 moderating the choice of journal.

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What makes science news?

by Cathy Holding

This article is aimed at the writer who wishes to branch in time: for example The Scientist requires two other voic- into freelance and who would like to es to comment on the paper in question, and getting all know how. Science news can be a reasonable source of these interviews set up, carried out, recorded, transcribed income for anyone who can write scientifically yet at a level and written into the article by the deadline can be really that is accessible to the non-specialist. It can be hugely stressful! enjoyable and rewarding, and nothing can beat the feeling of seeing your name and your article live on-line, or in print. Pitching Pitches are the means by which the writer draws the atten- Selling science news tion of an editor to a news article. To sell a story, a free- As with any form of writing, science news is a product that lance writer must pitch well. So what constitutes a good must be aimed specifically at a market. It is therefore nec- pitch? “Something I can read quickly,” says Alison. “Short essary to carry out research into what the markets are, and enough that I can visualise what the first sentence is going to read the stories that are published in target magazines in to be; and it doesn’t just say what you want to write about, order to know the type of reader the stories are aimed at. but why it’s important.” Both The Scientist and New Alison McCook, News Editor for The Scientist (www.the- Scientist have pages on their websites that provide instruc- scientist.com) explains. “You really need to demonstrate tions for freelance science on how to write you know our audience. I get a lot of pitches, and some- pitches and articles for them. Some people pitch a press times I think, if only this person had read a couple of our release to the editor—but this may be counterproductive in articles…!” the case of editors who prefer a pitch demonstrating the ’s clear understanding of the nature and implica- Problems facing Freelancers tions of the paper. It may be difficult for freelancers to sell science news sto- Regarding editorial response, you are likely to get more ries to certain sectors, because some of the bigger science rejections than acceptances but these should never be taken magazines, such as The Scientist, now employ their own personally. If the editor adds a sentence along the lines of, in-house staff. Alison highlights the problems facing free- “Thanks but no thanks, but please keep pitching!” then you lancers. “Before we were largely freelance and now we’ve are doing pretty well! The problem for freelancers is that it switched. We now put out at least two or three freelance can take a decent amount of time to construct a pitch, from stories per week—two years ago, ninety percent of every- reading the paper and perhaps some background papers too, thing we did was freelance.” However, she encourages all to writing the pitch and finally waiting for the response. If writers to go for it. “The topic is just science, that has the pitch is rejected, then the work goes unpaid. always been what we focus on, that’s our trade—anything You should be prepared to be edited, although that’s not related to life, even organic chemistry, behaviour, ecolo- always the case. “Often articles are fine and I don’t need to gy—as well as all the molecular biology,” she says. edit very much,” says Alison. However it depends on the Problems facing freelancers include competition: the in- ; New Scientist edited my article very heavily so house staff skim the big stories off the surface of the ocean that it sounded more in-house. “As long as it’s within our of science publications each week, with the result that the general style,” agreed Alison. freelancer has to dive a bit deeper, and therefore with more News does not have to be restricted to the news section of skill, to find those more rare species that he can sell to earn a magazine either; you can pitch to other sections too. For his crust. Other freelancers may have spotted the paper and example, The Scientist has a section called the Notebook. be pitching the story too: often commissions are handed “They’re very short pieces but they touch on important top- out on a first come-first served basis, but not all publishers ics,” Alison explains. “So it might be the story behind some do that. The Scientist commissions are now based on merit, really interesting science; you know the people working on not speed of typing or time zone, making it just that bit eas- it and what led them to come up with this finding, that sort ier for a good journalist who gets up a little late! The need of narrative article.” In addition she adds, “You’ll see from to pitch the story to the editor during the time that the paper our website we cover another category we broadly call is under embargo will also lose you a day or so. Another “policy” stories, meaning anything that’s affecting how life problem for the freelance journalist is setting up interviews scientists do their work.” >>>

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>>> What makes science news? Sources for science news When receiving press releases it’s a good idea to trawl So where does a science journalist get the news from? It through all the titles in the release, not just those that have seems that no sooner has a paper been published than it’s been written up; with your insider knowledge you may spot already been written about, so how does a lowly freelancer something the authors may have missed. get hold of the papers? The answer is that journalists are Usually for the news desk, editors want embargoed papers. given privileged access to papers from various sources a However, I wrote a news article for New Scientist that had few days before they are due to be released for publica- been published for a couple of weeks already, but whose tion—these are called embargoed papers. But beware— implications had obviously been missed by other reporters journalists may not publish anything about embargoed when I stumbled across it. But this is a very costly way of papers until the embargo date is passed, under pain of deriving news; a huge amount of trawling and very little excommunication. (As a cautionary tale, you can read reward. If you go for a particular journal frequently that does about the breaking of the JAMA embargo on the National not issue press releases, it may be worth while contacting the Heart, Lung, and Blood Institute (NHLBI) Women’s editor and requesting that he forward papers of interest to you Health Initiative (WHI) clinical trial that was unexpected- before they are published so that you stand a chance of get- ly stopped early because it showed that the risks of combi- ting the news out the moment the paper goes live. nation oestrogen-plus-progestin therapy outweighed the benefits for postmenopausal women, with implications for The bottom line millions of women taking hormone therapy[1].) The embargo provides enough time to set up interviews and So how much money are we talking for freelancers? “It write the article to coincide with the release of the paper. varies, it’s 80 cents a word for news [at the time of publi- cation of this article]; we always negotiate though, so if There are various websites that provide embargoed publi- someone wants more we can always talk about that,” says cations for journalists. For example, reporters and free- Alison. For a new writer she often works “on spec”: “This lancers can access embargoed and breaking news, peer- would be someone I haven’t worked with before, who I’m reviewed journals, experts and other valuable resources not completely confident about,” she explains. The new through EurekAlert! (www.eurekalert.org), an online, writer would be expected to write the article but not be paid global news service operated by AAAS, the science socie- for it unless it was actually used. “It’s sort of like a tryout. ty. The European equivalent for this site is Alpha Galileo If I can use it then I would definitely pay that person,” (http://www.alphagalileo.org/), and registered journalists Alison adds. have access to embargoed information and an email alert service that allows research areas of interest, type of con- How do you make science news? tent, languages spoken and dispatch time to be specified. So, finally, the question of what makes science news!? Also the Nature Publishing Group has a press site (http://press.nature.com/press), where weekly releases Alison found this question the most difficult. “It’s hard to from Nature, weekly joint releases from the Nature explain,” she said. “ It’s just something you didn’t know Research Journals, occasional releases from the Nature before, it’s about general awareness; like the one minor Review Journals, from the NPG Academic journals and paper we haven’t covered.” from the Nature Clinical Practice Journals can be accessed. Although certainly a gut feeling is involved, there are cer- It is necessary to register to use these facilities, and you tain questions that journalists should ask themselves, when will be asked to demonstrate that you are a bona-fide jour- reading a press release or a paper, which help in develop- nalist. This is usually done by providing evidence of previ- ing that instinctive feeling for a hot paper. Below I detail ously published news articles, or by proving that you are how I went about preparing a pitch for The Scientist recent- already working for an organisation (such as the BBC), or ly (it was rejected because they were covering a different by a reference from someone else working in a news paper in the same issue). organisation (for example, by getting the editor of the news The press releases, or even table of contents, provide the site to request access for purposes of writing the news arti- cle). For Alpha Galileo, it may be sufficient to submit proof first clues about whether a paper is newsworthy. The pri- of membership of a writer’s organisation such as EMWA, mary question is, what will the news headline be? Take for and if further information is required then the website will example the title of a paper from a recent edition of make contact. EurekAlert! definitely do require ‘clips’, or Science: “The Near Eastern Origin of Cat previously published articles; however if you register Domestication”[2]. Not the most news-grabbing title, but it through the website it is possible to enter into dialogue offered potential. After reading the paper, the title of the with them to discuss the issue. Once signed up to these news article became clear: “Cats domesticated over a hun- websites, you can receive press releases from various jour- dred thousand years ago”. If you can put the whole thing nals by email, and in the case of Nature some of these into a title that appears catchy, you’re on to a good start. arrive a short time before the embargoed papers are actual- The title has to encapsulate the results of the paper and ly released. make the reader want to read on.

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What makes science news?

Second comes the by-line, the sentence that goes under- neath the headline, which reiterates the main point, sug- Cathy Holding has written more than 150 news articles published gests the angle of the article and hopefully doesn’t give the in The Scientist (http://www.the-scientist.com) and New Scientist whole game away so the reader will read on! In this case it (www.newscientist.com). She is currently working as a freelance science writer. For more about Cathy see www.cathyholding.co.uk was, “Furry feline friends around far longer than first thought”. Again, if you can encapsulate the paper in this way, then it’s likely to have news potential. (Incidentally that by-line may have been a bit too informal for The Scientist). Third, the first sentence of the article or pitch has to say it Are embargos all again in more detail. This is the sentence that Alison in the public interest? McCook referred to above regarding short pitches. In the case of The Scientist, the first sentence must be 30 words Vincent Kiernan has written a very interesting essay or less. Here, I chose, “All domestic and wild cats are entitled ‘The Embargo Should Go’, adapted from his derived from 5 mitochondrial DNA lineages which date as book Embargoed Science. far back as a hundred thousand years, prior to any other Kiernan argues that while embargoes are convenient for archaeological record of domestication, according to journalists and suit the scientific journal world they do research published in ScienceExpress this week.” Once not serve the public interest. He contends that regardless again, if the results of the paper can be captured in this of if the research being reported is good or bad news the way, the odds are looking good for a news article. scientific and medical establishments are always cast in a positive light, as the font of new findings. Journalists Fourth, it has to be clear why it’s important. I reckoned are so preoccupied with writing about research, which is that, “this should appeal to archaeologists and human spoon fed to them, that they do not have time to question behaviourists, to groups interested in cat populations and to and investigate the workings of science and medicine. If domestic cat owners in general.” they were freed from the tyranny of the embargo they would have time to visit scientists in laboratories and The authors themselves usually understand why their work troll for investigative stories. is important, and it’s a good clue to go to the conclusions. In this case, the authors felt that archaeological imprints The trump card for embargo supporters is that science is have been left in the genomes of living cats and give clues complex and journalists need to prepare articles from about the timing, steps and history of domestication. It research articles to ensure their accuracy. But when would seem that the process began well over 9,000 years other journalists are able to report complex news about ago while farmers in the Near East domesticated grains and court decisions and tax laws without an embargo system cereals as well as livestock animals. Meanwhile, wildcats Kiernan questions if this is not an insult to the intellect of the region may also have adapted by regulating rodents of scientific journalists. in grain stores and abandoning innate aggressive behav- The essay casts the Internet as a mixed blessing for the iours. Fascinating stuff! If you can make your reader think embargo system. In the short run it provides an easy it’s fascinating too, you could be on to a winner. means of distributing embargoed articles to journalists but in the long run the more journalists involved the Closing points more likely it is that embargoes will be broken. Thinking Writing science news is fascinating and challenging and further, at the moment few journalists are searching self- ultimately rewarding from a morale point of view, if not a archiving sites for news even though this is an early financial one! If you choose this line of work I wish good source of new research because scientists post preprints luck and offer the advice: be thorough, and be persistent! of articles on the sites. One journalist, Tom Siegfried, One caveat, however, from being published on the internet: who uses physics preprint servers for news of the latest the main thing you get from fame is spam! research, is quoted as saying that the role of physics journals is now largely limited to providing archival copies of important papers and for proving records for Cathy Holding tenure. Cambridge, UK [email protected] The essay concludes that it is time for science journalists References: to break out of their dependence on journals as a source 1. Fontanarosa PB, DeAngelis CD. The importance of the journal embargo. of science news, and for scholarly societies to stop try- JAMA 2002; 288(6):748-50. 2. Driscoll CA, Menotti-Raymond M, Roca AL, Hupe K, Johnson WE, Geffen E, ing to shape the flow of news in a way that suits their Harley E, Delibes M, Pontier D, Kitchener AC, Yamaguchi N, O’brien SJ, own political ends. Macdonald D. The Near Eastern Origin of Cat Domestication. Science 2007; Source: http://www.aps.org/publications/apsnews/200703/backpage.cfm 317(5837):519-23.

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Successful cross-cultural communication requires us to test our assumptions

by Geoff Hart

Everyone’s heard about the ignorant tourist who is visiting Understand the culture a foreign country and having difficulty communicating Most of us recognise the difficulty of dealing with other with the natives. The tourist tries to communicate in cultures, and are willing to at least make an effort to adapt English, our modern lingua franca, and when the native fails our communication style. Those of us who speak English to understand, the tourist repeats exactly the same sentence, as our first language, and particularly North Americans, but louder and slower. After all, everyone must speak recognise English’s role as an international language, and English, so the problem must be volume and pacing. At best, tend to assume that other cultures will make an effort to both people shrug, smile placatingly, and move on, having accommodate our linguistic imperialism. It’s certainly true failed to communicate; at worst, tempers rise, and both leave that people of a host country will try to extend a host’s with greatly reduced respect for the other person’s culture. courtesy to visitors who don’t speak their language, but we shouldn’t rely on this in our professional communication. It would be nice if we all spoke dozens of languages and Making even a simple effort to learn a host country’s cus- could avoid such problems, but in reality, most of us lack toms lets us show respect for their culture, and that respect that skill. Instead, we face the tourist’s problem whenever is returned. In contrast, failing to make that effort can lead we try to communicate in our own language with col- to resentment, and that can compromise even communica- leagues or clients from other cultures. The most common tion that would otherwise be clear. Once offence is given, communication problems arise when we assume the other it’s too late; “you never get a second chance to make a first person thinks the same way we do and shares our under- impression”, and that first impression can interfere with all standing of what we’re trying to say. We writers make this subsequent communication. mistake less often, because we’ve learned to identify and eliminate such assumptions in our writing; this lets us add As communicators, we should strive to understand other the missing context or explain our hidden assumptions to cultures well enough that we can at least avoid the obvious ensure we communicate successfully. But we’re not traps. Something we writers often forget, focused as we are immune to the problem either, particularly in oral commu- on words, is that communication begins long before we nication, when we have less time to revise our words. have a chance to exchange many words. For example, busi- ness meetings often begin with an exchange of business People who live where interactions among multiple lan- cards. North Americans tend to glance briefly at a card guages and cultures are part of everyday life have an enor- before shoving it into a pocket. In China, this would be mous advantage over North Americans, for whom multilin- insulting behaviour, so before travelling in China, I trained gual and multicultural communication is an exceptional myself to accept an offered card with both hands, read it situation. For example, many Europeans and Asians can carefully, pronounce the name and smile, and ask whether communicate effectively, if not elegantly, in a second or I had pronounced the name correctly. In return, I offered third language, but most North Americans are stubbornly my own card with both hands simultaneously, held so my unilingual. Unfortunately, familiarity with a multilingual colleague could read it without having to turn it around. context doesn’t ensure successful communication either; The effort was always appreciated. despite my multicultural awareness, I repeatedly forget the In most Asian cultures, establishing a friendly relationship difference between US letter-size paper and European A4, must precede efforts to focus on business, and if you don’t and even though I live in Canada, a British Commonwealth understand this, you’ll receive a cool reception. When I nation, I work with so many American authors that I tend communicate with Asian colleagues, I consciously try to to assume US English is international English. It seems to break my North American habit of writing concisely and be fundamental to human nature that we assume our audi- getting quickly to the point. After I’ve completed the initial ence shares our assumptions, and that’s only rarely true. formalities, I’ll often comment on the weather or any inter- With practice, we can learn to consciously use the same esting work I’ve been doing, and during our annual thought process we use to clarify our writing whenever we Chinese lantern festival (Shanghai ships thousands of must use our own language to communicate with someone handmade silk lanterns to Montreal each year), I’ll mention from a different culture. In this article, I’ll explore some this to my Chinese colleagues and send them a link to pho- ways to increase the likelihood of success. tos. Many reply with pictures and anecdotes of their own.

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Successful cross-cultural communication...

Even within multicultural Europe, cultural differences can dis- on the faces of actors so that even subtle and nuanced ges- rupt communication. Germany, for example, is a stereotypical tures and facial expressions are clearly visible. Particularly low-context culture that values direct, concise, straight-to-the- now that we can watch a movie on DVD, they know we can point communication, whereas Spain is a high-context culture replay a scene if we missed something. But at a live per- that values relationships and the context surrounding commu- formance, we’re farther from the actors and can’t replay nication (http://en.wikipedia.org/wiki/High_context_culture). scenes, and we must concentrate to exclude distractions such Although such stereotypes can mislead us, deep cultural as the scenery; even for those in the front row, there are no roots may underlie a stereotype and explain why people ‘extreme close-ups’. That forces performers to speak louder communicate in a certain way and how we can accommo- and exaggerate their gestures to ensure that nobody will miss date that approach. In urban Quebec, for instance, conver- what they’re trying to communicate. As a result, stage per- sations switch back and forth between French and English formers sometimes appear to be ‘over-acting’ on television as speakers choose the language that offers the most flexi- because they haven’t yet learned to overcome these habits. bility to express a given concept or to help less-skilful When we speak to someone in a language they don’t under- speakers who are having difficulty. Conversations that stand well, we must reverse that process to some extent. begin in the group’s majority language soon become a Suppress your reflexes Babel of multilingual idiom. This is a common pattern: Each of us develops certain communication reflexes that those who try to understand and accommodate people from become subconscious. People who know us well can learn to another culture are accorded equal respect. understand them, but others may not be so fortunate. For example, I type ‘’ frequently in my e-mail messages; the Speak slowly ‘g’ stands for ‘grin’, and is the equivalent of the smiley face The tourist who speaks slowly but loudly seems foolish, icon. In North America, this identifies a comment that should but there’s logic to this approach. When we must speak to not be taken seriously, and it’s a useful way to emulate the way a foreign audience in our own language, we must remem- we smile during a conversation to ensure that listeners will ber that they lack our experience with the language and understand what we’re saying as an attempt to amuse and cannot easily compensate for faults in our speech. engage our conversational partners. Recently, I typed in Speaking slower (without emulating a dying tape recorder) an e-mail message to a Filipino colleague whose impeccable gives them time to recognise individual words and deter- English led me to assume she would understand. Her reply mine their meaning; speaking louder (without shouting) made it clear that she hadn’t understood, and because I was makes the words more distinct because it focuses our atten- paying attention, I noticed this and was able to explain what tion on pronouncing words distinctly. It’s not the volume or I’d done. Paying attention to her nonverbal cues told me I’d pace that is important, but rather the effort to concentrate behaved reflexively without confirming that she would under- on the words rather than using all the bad habits we’ve stand, and correcting the problem led to an interesting conver- acquired from over-familiarity with our language. sation that taught me much about the Philippines. This approach is particularly useful when working with Because these kinds of reflexes are subconscious, we tend interpreters. When I spoke about technical communication not to notice them, but we can at least learn to pay atten- during a visit to China, I consciously spoke louder and tion to how people respond to what we say and do. It can more slowly than usual (I have a quiet voice and speak fast be helpful to ask a friend to point out what we’re doing when I’m excited), and paused and relaxed between sen- wrong; once we’re aware of a problem, we can learn to tences. This gave audience members who spoke some suppress it. More often, we must identify potential prob- English more chance to understand what I was saying, and lems ourselves because we won’t have someone to monitor gave the interpreter time to reiterate what I had said in our actions. Before travelling to India, I learned that food Chinese without feeling rushed. In addition, I paused should not be touched with one’s left hand—problematic, slightly longer than usual after displaying a new line of text given that I’d spent much of my life eating this way. For in PowerPoint so everyone had a chance to read and absorb the month before my trip, I actually sat on my left hand at that line before I began speaking about it; because most the start of each meal until I’d learned to touch food only people understand written language better than its spoken with my right hand. form, this increased the likelihood my audience would cor- rectly discern my spoken words. I also printed my presen- Both examples show how learning what might offend my tation for the interpreters, along with explanations of diffi- colleagues and looking for their reactions would let me cult or technical points, and gave them copies well before look for bad habits I needed to suppress. Only when you’re my talk so they had time to understand my presentation and aware of a problem can you try to solve it. ask me about anything unclear. Suppress language reflexes The difference between speaking your own language to a Similar problems arise in our writing and speech, often compatriot (in the original sense of that word, namely from unconscious assumptions that shape how we frame someone from your country) and speaking to someone our thoughts. Idiomatic phrases are a particular problem, as from another culture is analogous to the difference between they differ dramatically between cultures. In Quebec, for movies and a live performance. Film-makers focus closely example, the French use obscenities based on Catholic reli- >>>

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>>> Successful cross-cultural communication... gious practice, whereas the English use obscenities based on Synonyms can also lead to confusion over the intended body parts and bodily functions. Most cross-cultural com- meaning. Technical writers learn a useful trick related to munication won’t involve obscenities, but I’ve chosen this synonyms: wherever possible, we use each word to convey example to dramatise how the sources of idiom differ. only a single meaning, to avoid words with multiple (poten- Another example is that many American idioms used in tially confusing) meanings, and to avoid using two words to business writing are based on sports, such as ‘getting to first communicate the same meaning. This eliminates three base with a client’ (baseball) or ‘making an end run around potential sources of confusion over the meaning of a word. an obstacle’ (American football). This is less common in The European Association of Aerospace Industries' Simplified non-English cultures, but also varies among English cul- Technical English (http://www.simplifiedenglish-aecma.org/) tures; for example, the British might speak of a ‘sticky wick- takes this approach to extremes, because its practitioners et’ (cricket) to refer to a difficult or embarrassing situation. face a uniquely difficult challenge: creating English that will Verbs also pose problems, and not just because languages be understood correctly, after some training, by culturally differ in their preferred verb tenses and in verb conjugations. diverse audiences around the world. (Translation and locali- For example, the subjunctive is a dying part of English and sation would be a better solution, but when you’re translat- passive voice is discouraged, whereas both are alive and ing thousands of pages of complex documentation into well in French. Phrasal verbs pose particularly serious prob- dozens of languages simultaneously, this may be logistically lems, because they are idiomatic and thus, metaphorical. For and economically impossible.) example, the phrase ‘served notice’ requires an understand- ing that ‘serving’ means ‘delivery’ and ‘notice’ means you Conclusion want the person to notice something; ‘informed’ or ‘alerted’ Successful cross-cultural communication depends on the says this more clearly because both verbs are largely free of same skills we use to write clearly: we must spend the time metaphor. But even the non-metaphorical ‘have to’ is not required to understand our audience, identify our assump- immediately obvious because ‘have’ indicates possession; tions, and determine whether the audience shares those ‘need to’ or ‘must’ are easier to understand. assumptions. When they don’t, we can make our assump- tions explicit or choose a different approach so the audi- Complex sentences containing parenthetical clauses are ence shares our understanding. Some of the assumptions another problem, particularly in speech. Our audiences are we make are cultural, others are linguistic, and others com- not stupid, and will eventually be able to untangle the mean- bine aspects of both. But all these assumptions arise from ing of such sentences, but doing so requires more effort. The the same root: even when we’re communicating with some- problem relates to limitations on human short-term memory: one from our own culture who knows us well and shares our while reading or hearing our own language, we process the language, they exist in the separate world of their own components of a sentence easily and extract their meaning mind. It’s the gap between those worlds that creates differ- rapidly. But understanding a foreign language is slower, and ent assumptions and different interpretations of the world. we often lose the last part of a sentence while our attention is focused on understanding the first part. In speech, we can Editors understand this problem because we spend much of slow our pace to avoid this problem; in both speech and writ- our careers solving problems that result from authorial ing, we can break longer sentences into shorter ones, or sim- assumptions readers don’t share. This statement reflects plify the sentence so the parenthetical information and claus- more than just pride in my profession. I’m the author of es are easier to identify and understand. more than 300 published articles, and each one has been a new lesson about my ignorance of my own assumptions. Synonyms are yet another problem, particularly for English, which has the world’s richest vocabulary. As Learning to edit our own writing minimises such ignorance James Nicoll famously observed, “We don’t just borrow because we learn to test our assumptions, but the lesson is words; on occasion, English has pursued other languages stronger when someone else does the teaching; each of us down alleyways to beat them unconscious and rifle their is somewhat blind to our own assumptions. Successful pockets for new vocabulary.” As writers, we take great cross-cultural communication requires us to learn enough pleasure flourishing our vocabulary, and English offers of other cultures that we understand how their assumptions many words to abuse in this way. Unfortunately, it takes differ from ours, then apply the same critical skills we learn considerable time and effort to acquire such fluency, and in from editing our written communication and having it edit- cross-cultural situations, most of our audience won’t share ed by others to reveal our own assumptions. our skill. For such audiences, simpler is better. Metaphorically, a ‘$10 word’ is longer, more complicated, Geoff Hart or more obscure, and thus ‘more expensive to purchase’ Montreal, Canada than shorter, simpler, more familiar ‘$1 words’. But in a [email protected] very practical sense, the $10 words are also more expen- sive in terms of the mental effort audiences must exert to Geoff Hart has published more than 300 articles on scientific and understand them and in terms of the cost of failed commu- technical communication, including the book Effective Onscreen nication. Using simpler and more familiar words seems to Editing (www.geoff-hart.com/home/onscreen-book.htm). He works as a scientific editor and French translator who specialises in helping suppress our creativity, but we still have ample opportuni- authors from many cultures publish their research in English. ty for linguistic virtuosity when we use simpler words.

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Transparency in medical writing: Medical writers leading the way

by Jenny Fanstone

In recent years, the role of medical writers has come under introduction of this policy. Others who have tried to do a increasing scrutiny from both the medical and lay press and similar thing have experienced negativity from their it is important that we, as medical writers, take positive clients. It invariably emerges that when approaching the steps to be open and transparent about our work. To pro- client with their recommendation, writers and agencies vide guidance to our writers, clients and authors, and from don’t have a policy document – they mention that it would our own need to be seen as an ethical company, Caudex be good to include a statement and may do so at the end of Medical Ltd. has created an acknowledgements policy that the manuscript-writing process, but still they encounter offers leadership in achieving this transparency. great reluctance and inevitably the experiment falters. Caudex experience has shown that the key is in having a Caudex Medical acknowledgements policy policy document to back up your suggestion; by showing it Caudex policy was developed following a review of posi- to your client, they can see the careful consideration that has tion statements and information provided by key medical gone into your proposal. Through the inclusion of refe- writing, publications and pharmaceutical industry associa- tions, including EMWA, ICMJE, GPP and WAME. At that rences to statements made by medical writing, publisher time, the EMWA guidance was the most comprehensive; and industry associations, it is possible to demonstrate the furthermore, it affirmed the value of the involvement of research that has been done and the weight of support professional writers in medical communications, reflecting behind the initiative. And with journals increasingly includ- our aims in creating an acknowledgements policy. Caudex ing the requirement for such disclosure in their Instructions thus decided to align itself with the EMWA guidelines. to Authors, the need for transparency is easy to prove.

Acknowledgements statements Client response Having created an acknowledgement statement, Caudex In our experience, the Caudex acknowledgments policy has recognizes that in some circumstances, flexibility in the been received favourably both by new clients, to whom we wording is essential. Journal requirements and the role that have introduced the policy at pitch stage, and established either an individual writer or a team from Caudex have clients with whom we have been working for substantial played in the writing process are two such cases, and so periods of time. In each case the client has recognized the options exist for either ‘Caudex Medical’ or the individual proactivity of Caudex in this field and held us in high regard writer’s name to be included. In all cases, the involvement for our stance, and it is felt within Caudex that this factor of the sponsor is disclosed. may already have been an extra point in winning business. The default statements recommended by Caudex are: The policy has been accepted well by authors, also; indeed, by including it as a default addition to every manuscript at The authors take full responsibility for the content of this first draft stage, it is seldom remarked upon, and seen as a paper but thank Caudex Medical (supported by sponsor natural and automatic part of the writing process. name) for their assistance in preparing the first draft of the manuscript* and collating the comments of the authors and Choosing to work with an ethical company that is proud to other named contributors. stand up and be seen to be acting ethically reflects well on our clients in the eyes of both clinicians and, we hope, jour- Or, if acknowledgement of the individual writer is preferred: nal editors. The authors take full responsibility for the content of this paper but thank name plus qualifications (Caudex Jenny Fanstone Medical; supported by sponsor name) for their assistance Caudex Medical Ltd in preparing the first draft of the manuscript* and collating Oxford, UK the comments of the authors and other named contributors. Acknowledgements The Caudex Medical acknowledgements policy was written by Chris Deakin, Including your clients Jackie van Bueren, Jackie Marchington and Philip Loder. The author would like to thank Chris Deakin and Jackie van Bueren for their contributions to this article. From its inception we have been repeatedly asked by other Caudex Medical would like to thank Liz Wager (SideView) for her advice during writers and agencies how our clients have reacted to the the finalization of the Caudex Medical acknowledgements policy.

* Adapt role if necessary

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Word 2007—rejected with an invitation to revise and resubmit

by Karen Shashok

Last summer Microsoft unleashed Word 2007 upon the publishing industry without warning users of the changes A sample of publishers’ requests that authors avoid in the software’s features that made adapting to the latest Word 2007 (all accessed on 29 August 2007) version a challenge. As a result of backward compatibility 1. Guidelines for Electronic Submission, Text, Software and usability problems, leading journals (including Science and format. “Microsoft Word 6.0 is preferred, although manuscripts prepared using any other microcomputer and Nature) were obliged to announce they could not word processor are acceptable. Please note: This journal accept manuscripts prepared with Word 2007, or to ask does not accept Microsoft WORD 2007 documents at authors to take special measures to ensure their manuscript this time. Please use WORD’s ‘Save As’ option to save files could be processed (see Box). These measures include your document as an older (.doc) file type.” saving files as an older (.doc rather than .docx) file type, as Source: Journal of Surgical Oncology, Instructions for Authors. http://www3.interscience.wiley.com/cgi- requested by Wiley and Blackwell, or using Equation bin/jabout/31873/ForAuthors.html Editor or MathType (equation editors included in previous 2. “Please note: This journal does not accept Microsoft versions of Word) instead of the default equation editor Word 2007 documents at this time. Please use Word’s included in Word 2007, as requested by Springer. As of this ‘Save As’ option to save your document as a .doc file writing (6 September 2007) had not announced type. If you try to upload a Word 2007 document in their policy regarding Word 2007 files. But mc strategies, Manuscript Central you will be prompted to save a healthcare e-learning company owned by Elsevier, has .docx files as.doc files.” been offering online IT courses in each of the four applica- Source: Echohydrology, Instructions for Authors. http://www3.interscience.wiley.com/cgi- tions in Microsoft Office 2007, including Word 2007, since bin/jabout/114209870/ForAuthors.html the product was released in June 2007 [1]. 3. “Word 2007. Will authors please note that Word 2007 The compatibility problems with Word 2007 made it is not yet compatible with journal production systems. Unfortunately, the journal cannot accept Microsoft impossible to submit .docx files via online manuscript sub- Word 2007 documents until such time as a stable pro- mittal and management systems, and were an impediment duction version is released. Please use Word’s ‘Save to editing and production since publishers’ current systems As’ option therefore to save your document as an older could not handle the new file format. Moreover, mathemat- (.doc) file type.” ical formulas created with Word 2007’s default proprietary Source: Blackwell, European Journal of Neurology, Author Guidelines. math and equation editor (accessed via the Equation Tool http://www.blackwellpublishing.com/submit.asp?ref=1351-5101 ribbon) were converted into uneditable graphics objects in 4. “Note: If you use Word 2007, do not create the equa- .docx files that were saved as .doc files and opened in ear- tions with the default equation editor. Use MathType or the equation editor included in previous versions of lier versions of Word. Word instead.” How did the snafu come about? Bruce Rosenbaum of Inera Source: Springer, Instructions to Authors. http://www.springer.com/cda/content/document/cda_downloaddoc- Inc, one of Nature Publishing Group’s main suppliers of ument/instruct-authors-e.pdf?SGWID=0-0-45-392601- Word macros, explained: 0&teaserId=343495&CENTER_ID=357799 Most publishers are a long way from upgrading to 5. “Equations. Word 2007 users please note: With Word 2007 Microsoft has introduced a new proprietary math Word 2007. There are two main reasons for this editor as the default editor for equations, but there are delay. First, other systems in the publication work- incompatibilities which prevent us from using equations flow, most notably online submission/ created with this new editor. Please use the Design systems and editorial tools, are not yet compatible Science Equation Editor (formerly the default Word edi- with DOCX files. If the surrounding infrastructure tor) or MathType rather than the new default math edi- tor featured in the Insert ribbon. To use either Equation doesn’t support DOCX, there’s no impetus to switch Editor or MathType, in the Insert ribbon, click ‘Object’ internally. Second, the user interface is very different and choose object type ‘Microsoft Equation 3.0’ or from previous versions of Word, and this change ‘MathType Equation.’ The Equation Editor toolbar or brings transition issues, especially with editors who MathType window will appear and will work as in pre- vious versions of Word.” may balk at the degree of change and see Word as a Source: JBC (Journal of Cell Biology), Rockefeller University Press, tool to do their work, not a tool to relearn with each Instructions to Authors. http://www.jcb.org/misc/ifora.shtml new release [2].

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Word 2007...

A related posting on Inera’s website added enlightening Had the conversion from DOCX to DOC provided a details about the situation: conversion from OMML to Equation Editor format, it would have provided the necessary backwards com- It has recently come to Microsoft’s attention that Nature patibility for publishers to upgrade one system at a (http://www.nature.com/nature/authors/submis- time. But because this compatibility is not available, sions/template/index.html), Science (http://www.sci- it‘s created the need for a “big bang” upgrade, or a encemag.org/about/authors/prep/docx.dtl), and many delay until the ecosystem of interdependent systems other scholarly publishers do not accept files is deliberately updated over time. In the environment authored in Word 2007. The following was sent by of scholarly publishing, such substantive upgrades Inera CEO Bruce Rosenblum to Microsoft on June often take years, not months. 12, 2007, to explain why this situation exists: I hope this post clarifies some of the core issues [...] As a result of Microsoft’s success with Office, DOCX format presents scholarly publishers and and the relative stability of the Office environment explains Word 2007 issues that are cause for publish- and DOC format over that time, third parties have er upgrade reticence. Those of us in the scientific built sophisticated applications to address specific community look forward to a dialog to articulate vertical market requirements for integration of Word scholarly publishing requirements to Microsoft so into highly efficient workflows. that Microsoft can provide products that serve the eXtyles® is one such application; eXtyles is a suite needs of the entire scholarly community [3]. of editorial and XML tools for Word in wide use by A press release dated June 22, 2007 from , scholarly publishers. [...] Other tools include online the firm that develops the MathType and Equation Editor submission and peer review applications, and other software used in Microsoft Office, provided information applications used in the post-editorial production on progress toward solving the problems created by the workflow. new default equation editor in Word 2007: Like eXtyles, most of the applications in this work- Authors are encouraged to continue using Equation flow ecology are not yet compatible with DOCX for- Editor (Microsoft Equation 3.0) or MathType with mat. For example, I surveyed the four largest vendors earlier versions of Microsoft Word. Design Science of online submission and peer review systems this has also published a technical support note week, and none support DOCX files. Nor could any (http://www.dessci.com/mt/tsn124) that explains of the four provide me with a date when they expect how to make Equation Editor easier to use in to have native DOCX compatibility. Microsoft Word 2007. If you detect no sense of urgency to upgrade systems In related news, Design Science is preparing to in this vertical market, you are not mistaken. For release MathType 6.0 for Windows, a major new ver- sion addressing the needs of Word/PowerPoint 2007 most scholarly publishers, the challenge is to publish users. Currently in beta, with release expected within high-quality and accurate information on a regular a month, this new version will allow authors to pre- schedule. Software upgrades to critical publishing pare submissions compatible with scientific journals’ systems, unless they are seamless or provide a signif- workflows. [...] [4]. icant immediate benefit, are often not a priority. On Nascent, Nature’s on web technology and science, In the case of Word 2007, upgrading is not seamless. Howard Ratner, speaking as Chief Technical Officer of Because files incorporating OMML equations are not Nature Publishing Group (NPG), reported in a posting semantically backwards compatible with older ver- dated 14 June 2007 that “Both Science and NPG have been sions of Word, publishers must update an entire ecol- in correspondence with Microsoft staff on this important ogy of systems before they can accept DOCX files. issue” [5]. In his 27 August 2007 posting he reported that Completing such updates requires work with third Nature and Microsoft have been examining together “how parties, careful testing, training, and finally deploy- Microsoft, third-party vendors and publishers can work ment—often one system at a time—of updated appli- together moving forward to make Word 2007 work within cations. All of this takes time. the STM publishing ecosystem” [6]. In the meantime, because a DOCX file with OMML I wonder why this latest incident with a Microsoft product equations renders the equations as graphics when doesn’t seem to have opened publishers’ eyes to the risks used with today’s systems, it’s easier for publishers to of overdependence on proprietary systems that are notori- ask authors to refrain from submitting DOCX files ous for being imperfectly debugged and creating new prob- until every part of the workflow ecology is DOCX- lems with every upgrade. Open Document Format might compatible. [...] avoid much of the disruption to the workflow ecology >>>

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>>> Word 2007...

many users of Microsoft products experience, and References: 1. mc strategies. Professional Development and IT. Coming Soon! Software upgrades would probably be free of much of the stress that Applications. Available at Word users experience (not to mention the expense in http://www.mcstrategies.com/?a=services&c=prof_dev&s=coming_soon. terms of training and loss of workflow efficiency). As Accessed 3 September 2007. 2. Inera, Inc. Word 2007 Math. Available at noted by Johnathan Hunt on the Nascent blog, “Surely, if a http://www.inera.com/word2007math.shtml. Accessed 29 August 2007. document format transition needs to occur, Nature could 3. Inera, Inc. Word 2007 DOCX File Format. Available at transition to the ISO approved Open Document Format, http://www.inera.com/word2007docx.shtml. Accessed 29 August 2007. 4. Design Science. For Immediate Release. Word 2007, Equations, and Scientific supported by multiple vendors (even partially and grudg- Journal Submissions. Available at ingly by Microsoft)” [7]. For more information on Open http://www.dessci.com/en/company/press/releases/070622.htm. Accessed 29 August 2007. Document Format follow the links in its Wikipedia entry or 5. Nascent. Nature’s blog on web technology and science. visit the OASIS website at http://www.oasis- http://blogs.nature.com/wp/nascent/2007/06/word_2007_and_the_stm_publishe.html. open.org/committees/tc_home.php?wg_abbrev=office. Accessed 29 August 2007. 6. Nascent. Nature’s blog on web technology and science. http://blogs.nature.com/wp/nascent/2007/08/microsoft_and_stm_publishers_m.html. Karen Shashok Accessed 29 August 2007. Translator—Editorial consultant 7. Nascent. Nature’s blog on web technology and science. 12 Aug 2007, Grenada, Spain http://blogs.nature.com/wp/nascent/2007/06/word_2007_and_the_stm_publishe.html. [email protected] Posted 12 August 2007. Accessed 29 August 2007.

Are ‘QA findings’ always negative? I recently received the following question from Karl Kleine, If a fellow researcher wanted to demonstrate superiority of Epidauros AG, Bernried, Germany: one drug over another, you might ask her: ‘So, what were your findings?’ Here the word findings is neutral, until your colleague “I have been discussing with my colleagues whether 'findings' responds and says perhaps: ‘The findings were very good …’. in the QA context or in general is something negative, like a 'deviation from procedures' or indicates ‘non-compliance’. My Specifically in the QA context, you might prefer to say ‘No colleague, Michael Haberl, from a scientist's perspective, GLP issues’, but then you could argue that this suggests that argues that a ‘finding’ may also be positive, and that we an ‘issue’ is always negative (but this is not the case), and should not write ‘No GLP findings' in our inspection reports.” then we are back to square one. I see lots of QA reports from different companies and act I should stick with ‘No GLP findings’. Everybody under- upon them. In the QA context, a ‘finding’ usually means that stands what this means, and it is definitely positive. something has to be done to resolve the ‘finding’ to improve something. In this sense, it is negative, and in the QA context And we should never forget that those concerned with lan- always will be. In general, a ‘finding’ is positive or negative guage sometimes tend to ‘overdiscuss’ hidden meanings that if declared to be so, or neither—so it can mean anything— words may or may not have, or try to force a context-specif- and this has always been the case: it depends on the context ic meaning onto a word, some times unsuccessfully, and and whether the word is modified. sometimes successfully, thanks to the vagaries of language. If you show that your drug is not inferior to another and this But this takes time. is what you aimed to do, this is a positive finding. If you An example of the latter is the word ‘event’. 25 years ago, aimed to do this, and your drug emerged as inferior, this find- the question ‘Were there any notable events in your study?’ ing is negative. If your findings were inconclusive, they were would probably have drawn a very blank look from a study neither positive nor negative. manager, unless something really surprising had happened. If you failed to satisfy a criterion required by ICH, the ‘find- Now, in the context of drug licensing, everybody knows this ing’ that you did so is negative in the QA context. To me, ‘No can only mean ‘Were there any notable adverse events in GLP findings’ is a positive statement, because it negates the your study?’ When writing, of course, the word ‘adverse’ fact that a finding can be negative. The adjectival use of ‘no’ should always be there, but it is quite acceptable when speak- this way (‘no’ is an adjective, a noun, and an adverb!) is a ing to use ‘event’ on its own. And, as we see, this has already very frequent way of starting what is ultimately a positive happened with the word ‘findings’ when modified by the term statement in English. ‘GLP’. If it is not modified, its meaning is still neutral and In the QA context, if you say: ‘Were there any findings?’, of context-dependent, and I suspect it will remain that way. course you mean ‘Did you make any negative findings?’ But this is no problem, because this is the context-specific use of Alistair Reeves the word ‘findings’. [email protected]

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Still more myths about English (5)

by Alistair Reeves

Another 10 myths about English to follow Myths 1–20 in Myth 22: ‘Irregardless’ is US English previous issues [1–4]. Apart from some that are new to me, Another claim by an elusive ‘native speaker’. There cer- some old chestnuts have been thrown at me over the past 6 tainly will be people in the USA and UK, and indeed else- months at training events (see Myths 26–30), which, where, who would have no objection to irregardless in the although fallacies, are claimed by participants be ‘rules’, following sentence: Irregardless of the diameter of the ery- usually backed up by an elusive ‘native speaker’ some- thematous lesion, 0.5 cm ointment was applied. I hope they where in my questioner’s immediate vicinity or past. These are in a minority in both countries! Always read regardless old chestnuts enjoy astonishing robustness—but then old for irregardless, and give despite and regardless preference over irrespective. Irregardless does not exist, and irrespec- chestnuts wouldn’t be old if they didn’t, would they? tive very quickly leads to multiple-negative problems: Irrespective of the absence of X, we did not… looks very Myth 21: You have to say ‘those patients’ innocent, but I bet most readers backtrack to make sure that in the following situations they have understood this correctly. You are pretty much You have a sample of patients who have undergone hys- lost here as soon as you read we did not. terectomy. The aim was to perform laparoscopic hysterec- tomy, but some patients had complications and were con- Myth 23: ‘Whilst’ and ‘amongst’ are pompous verted to laparotomy. Your author writes: 223 patients were Neither is pompous. British English still uses whilst and enrolled. 201 underwent laparoscopic hysterectomy and 22 while, and amongst and among interchangeably. US English had to be converted to laparotomy. In those patients who prefers while and among, and US readers will assume that had to be converted to laparotomy, the duration of sur- whilst and amongst are evidence that an author is more gery…. OR You have 24/194 patients with grade 3 or 4 familiar with British English. The Oxford English Reference leukopenia under chemotherapy for cancer. 22 had grade 3 Dictionary confirms this for whilst but not amongst [5]. leukopenia and 2 grade 4 leukopenia. Your author writes: Some like to differentiate between the meaning of whilst In those patients with grade 4 leukopenia …. OR Your and while, preferring while as an indicator of time, and author writes: Major deviations are defined as those devi- whilst to mean although: While the patients are receiving ations which lead to the exclusion of the subject from the the infusion, vital signs must be monitored every 10 min- PP set. utes; Whilst the first potential investigator objected to the inclusion of subjects with perennial allergic rhinitis, subse- I was recently told that a ‘native speaker’ had said you had quent investigators did not. In our context, although is to use those ‘because you are talking about specific always better if you mean although, but the latter example groups’. Unfortunately I had to take all the vicarious is a perfectly legitimate use of whilst, as is: Whilst the chest ‘native-speaker’ wind out of this participant’s sails. How X-ray is being taken, please try not to breathe. on earth can you make a rule out of this, and why do you need the demonstrative pronoun (those) and not just ‘the’, Myth 24: ‘Administrate’ has now come into no article, or no subsequent noun? I am increasingly seeing common usage this, but I cannot understand why authors think it is better. ‘A native speaker told me this is now in common usage’: Can anyone tell me? This is certainly not a rule. the words of another participant. I suspect this is a lost cause, but even if administrate has come into common usage In all above instances, you can delete the noun after those (whatever that means), I am still quite happy to take a stance (e.g. In those who had to be converted to laparotomy) and against it and quote the EnglishPlus website [6]: “Administer this sounds much more sensible. In the third instance, you is the verb form for administration or administrator. The can substitute simple are for defined as, and you can actu- word administrate is an incorrect form of the verb created by ally get rid of of the subject too, take out a superfluous the, some who drop the -ion suffix of administration. Be careful and ‘hey presto’, you have a much better and simpler sen- when forming verbs from nouns that end in -ation, as the cor- tence: Major deviations are those which lead to exclusion rect verb form may not end in –ate”. Hence—incorrect: from the PP set, even though I would probably never write 400 mg/m² were administrated by infusion pump. Correct: this, depending on the context. 400 mg/m² were administered by infusion pump.

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>>> More myths about English Myth 25: Don’t you have to say and write Myth 28: And while we are dealing with old ‘an unique’ or ‘an hotel’? chestnuts: Isn’t there a rule that says you (Almost) perfectly answered by AskOxford [7]: “The form cannot start a sentence with ‘because’? an for the indefinite article is used before a spoken vowel The same participant as in Myth 21 hurled this old chest- sound, regardless of how the written word is spelt. If you nut at me with a triumphant glance, and again I had to apol- say an otel when speaking (which is now often regarded as ogise for taking the wind out of his sails, because the distinctly old-fashioned [in my mind, completely so, or answer is: yes, you can. Because respectable writers have affected—AR]), then it may be appropriate for you to write been doing it for many years, even if they were taught not an hotel; but most people say hotel with a sounded h, and to at school. It would be unusual to do this in the results should [therefore] write a hotel”. The fact that some don’t, section of a study report (but what’s wrong with doing and still say and write an hotel is evidence of linguistic something unusual now and again?). It is probably more insecurity: an hotel is supposed to sound educated. It does- suited to your introduction or methods sections, or discus- n’t. It is also not necessary to say an historic occasion… sion. For example, if you had intended to determine a par- (although I have seen a ‘rule’ in a USA grammar book that ticular variable in a study, but decided post hoc not to you say an historic occasion because the stress is on the because there were too many major protocol deviations or second syllable in the word historic, whereas you say a his- too many missing samples, why shouldn’t you say Because tory book because the stress is on the first syllable in the too many samples were missing, the analysis of … was word history—bit too complicated for me!). AskOxford abandoned? I appreciate you could say The analysis of … again: “By contrast, words such as ‘honour‘, ‘heir‘ or was abandoned because too many samples were missing, ‘hour‘ in which the ‘h‘ sound is dropped are written with but this may not be what you want to say and you may ‘an‘. Because ‘European’ is said with an initial ‘y’ sound, want to stress that it was ‘because’ there were too many which counts as a consonantal sound in English speech, it samples. One thing to bear in mind, however, is that when is said (and written) with ‘a’ not ‘an’”. This therefore also starting sentences with ‘because’ in English you are devi- applies to ‘unique’ because it sounds as of it starts with a ating from expected word order (subject, verb, object, ‘y’, so it is ‘a unique’ and not ‘an unique’. interspersed with adverbials, usually after the verb). This device should therefore be used infrequently when writing, The experts on this website also cover a further question I usually when you want to create emphasis. am frequently asked: “An abbreviation such as MP (Member of Parliament), which is pronounced em pea, Myth 29: And here’s another … Splitting begins with a spoken vowel, and so it is ‘an MP.’ the infinitive is bad style and a sign of Translated into our context, this means that you say and ignorance write ‘a follicle-stimulating hormone level of XX’, but ‘an This time it was a quiet participant at the back who put up FSH level of XX’, and this applies to any abbreviation that her hand and said ‘My boss says that splitting infinitives is sounds if it starts with a vowel—and there are plenty. bad style and a sign of ignorance. What’s your opinion?’ My opinion is that this boss has no idea what he or she is Myth 26: There is a rule that says you talking about. And that’s what I actually said to this lady. cannot start a sentence with ‘However’ Ignorance of what? If splitting the infinitive shows igno- There are a lot of old chestnuts around, and this one looks rance, then I and many others who seem to have been doing as though it will never crumble. I wish someone could hit a pretty good job for quite a few years have obviously been this one with a great big ‘conker’1 and blast it out of exis- ignorant for most of our lives. Try to avoid using the split tence. There is no rule. However, if you do start a sentence infinitives ‘to more than double’ or ‘to almost halve’ with- with ‘however’, and it does not mean ‘by what method’, it out making it obvious to your reader that you have tried to should be followed by a comma. avoid them—it’s just not worth the effort. Despite my say- ing this, AskOxford [7] says: “It is probably good practice Myth 27: There is a rule that says you to avoid split infinitives in formal writing”. I’d like to ask cannot end a sentence with ‘however’ them to define what they mean by ‘probably’ here and why Another very old chestnut, and again: no rule. If you do, it they say this, because they add the following cautionary should be preceded by a comma. Ending sentences with note: “Clumsy attempts to avoid them simply by shuffling ‘however’ is more of a spoken device; it is a perfectly legit- adverbs about can create far worse sentences”, and in my imate written device, however. experience they usually do.

1 Conker is British English slang for horse chestnut. I don’t know if it still happens, but when I was at grammar school in England, you eagerly awaited the ripening of the horse chestnut, gathered as many as you could, decided which might be particularly resistant, threaded some string through one of these conkers and tried to break another person’s conker on a string by hitting it hard. For some strange reason, only boys played ‘conkers’—but this was more than 40 years ago. There were all sorts of recipes for creating the ‘superconker’—various combinations of baking, boiling and soaking them in vinegar. They were named incrementally after the number of conkers they had conquered plus the number the last conker conquered had conquered plus 1 (note the crazy difference in English spelling here), i.e. if your conker had smashed 22 conkers, it was a ‘twenty-twoer’; then it smashed another that had smashed 25 and it suddenly became a ‘forty-eighter’ (22 + 25 + 1). Not a conker was to be seen lying on the streets in Northern England, and I remember being amazed during my first visit to Germany in 1961 that the streets were strewn with conkers, nobody picked them up, and all the cars and buses were actual- ly driving over them with no regard whatsoever!

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More myths about English

Myth 30: Isn’t there a rule that says that References: 1. Reeves A. Myths about English TWS 2006;15(1):22-24. ‘e.g.’ and ‘i.e.’ must be italicised? 2. Reeves A. More Myths about English TWS 2006;15(2):58-60. No. But it appears that this (spurious) convention is again 3. Reeves A. More Myths about English (3) TWS 2006;15(4):139-40. 4. Reeves A. 5 More Myths about English (4) TWS 2007;16(2):85-6. being propagated as a rule by those illustrious ‘native 5. Oxford English Reference Dictionary. OUP. 1996 speakers’ because I have been asked this recently at sever- 6. http://englishplus.com/grammar/00000172.htm (accessed 10 August 2007) al training events, and it has also reached old chestnut sta- 7. http://www.askoxford.com/asktheexperts/faq/aboutgrammar/hotel?view=uk (accessed 10 August 2007) tus. It may, of course, be house style or journal style—then you obviously follow it. This is linked to Myth 10 [2], where I dealt with the supposed rule that in vivo and in vitro must be italicised. If you want to italicise Latin terms, no- one can stop you. But you must remain consistent to be kind Picturing your subject area to your reader, and it is easier to remain consistent if you don’t do it. But the best reason is that it is not necessary. Medical writers wanting to envisage their subject area might find the medical animations at www.healthscout.com/nav/animation/1/main.html use- Alistair Reeves ful. The site has 38 animations on such conditions as Ascribe Medical Writing and Translation, Wiesbaden, Germany migraine, Alzheimer’s disease, osteoporosis, diabetes, [email protected] and urinary tract infections. Flash player is needed to www.ascribe.de view the animations.

Vital signs

Dear TWS, I enjoyed Alison McIntosh’s article, ‘Reading round your Am I pedantic or merely concerned for attention to detail? Take therapeutic area’, in the June issue [TWS 2007; 16(2):77- your pick, but please keep up the fabulous work with TWS. 8]. Might I make a suggestion for the website/book club? As a PWM (person with migraine: my preferred term Bryan Graham, since I'm not usually a patient, just someone susceptible Abington, Cambridge, UK to migraine, and I loathe the word migraineur), I would recommend Oliver Sacks' book Migraine to anybody Editor’s reply needing a concise and accessible guide to the subject. Thank you Bryan for these comments. Naturally praise is welcome but criticism is valuable because it prompts us to Michael Shaw Heathfield, UK try harder and strive to improve quality, which was cer- tainly lacking in the instances referred to. Of course med- ical writers should pay attention to detail and these com- Dear TWS, ments highlight the sort of inaccuracy and inconsistency As communicators, we are often quick to criticize but we should be looking for when proof reading. The inac- slow to praise. I’d like to do both in equal measure. curacies are inexcusable. The inconsistency was because TWS had no style rule for quotation of book titles in the I was richly entertained by the latest edition of TWS. It is text, and failed to rigorously applied those it does have to among the best issues I have read. However, as TWS is the reference format. official publication for an association of communications From now on the style for quotation of journals titles, i.e. specialists, I’m surprised to see glaring inaccuracy and italic script, will be consistently applied to book titles as inconsistency in a single issue. I refer to references to the well, both in reference lists and when cited in the text of splendid book that “is another reason that the comma and an article. In this case the correct book title is Eats, Shoots punctuation in general should not be ignored”. Small & Leaves: The Zero Tolerance Approach to Punctuation. wonder medical writers often encounter inaccurate refer- The author’s correct name is Lynne Truss and the correct ences if the following are a representative sample: format for the reference list is: Lynne Tullis’ book Eats shoots and leaves (p45) Truss L. Eats, Shoots & Leaves: The Zero Tolerance Approach to Punctuation. London: Profile Books Ltd, 2003. Lynne Truss’ phenomenally successful ‘Eats, Shoots and Leaves’ (p53, cited on p56 as Truss L. Eats, Shoots and A greater effort will be made in future to check the mas- Leaves. Profile Books Ltd. London, 2003) ter proof for inaccuracies and inconsistencies. Volunteers to help with this task and join the copy editing team Lynne Truss’s book Eats, Shoots & Leaves: The Zero would be very much appreciated! Tolerance Approach to Punctuation (p62, cited on the same page as Truss L. Eats, Shoots & Leaves: The Zero Tolerance Approach to Punctuation. London, Profile Books, 2003) Elise Langdon-Neuner

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To smiley or The awful English language not to smiley? I am repeatedly seeing ‘lead’ and not ‘led’ as the past tense of ‘lead’ (Repeated administration lead to accumu- The electronic communications world lation in the plasma). I have also found that I have writ- seems to be divided between those ten this. The spellchecker does not catch this, of course, who cheerfully tag1 a smiley onto the so it is up to our eyes to do so. Add this to your list of end of almost every posting and those words that you check with ‘Search and replace–Find who suffer trauma if a smiley inadver- next’ (and not with ‘Replace all’) before you pronounce tently pops into a message bearing their a text to be ‘final’. Yet another reason to reform English name. This last group view the smiley as a sign of an spelling! uneducated writer and are supported in their distaste by the New Hacker’s Dictionary: “Overuse of the smiley is a mark of loserhood! More than one a paragraph is a Alistair Reeves fairly sure sign that you’ve gone over the line”. [email protected] The smiley started life as a design for an insurance com- pany but its creator, Harvey Ball, failed to register an intellectual property right to the image when he designed it in 1963, allowing it to fall into the public domain. An Is there a correlation enterprising couple known as the Murray brothers, who between proficiency in coined the phrase ‘have a happy day’, popularised the image by using it on the novelty items that they pro- English and publication in duced. By the late 1980s it became widely known as an ISI-indexed journals? icon of the acid house dance music culture and was being engraved on ecstasy tablets [1]. Research into this question is ongoing at the Federal University of Rio de Janeiro, Brazil. Brazil’s share of The smiley was first used as a text symbol in 1980 by publications in ISI-indexed journals has increased from Scott Fahlman, a research professor at Carnegie Mellon 0.4 to 1.6% over the last 25 years. This could reflect an University's Department of Computer Science, who increase in researchers or in international cooperations posted it on the university bulletin board. Michael but the study’s preliminary1 findings suggest it is more Quinion champions the smiley’s place in electronic related to the writing skills of scientists. communication in his article ‘Should the smiley be out- lawed?’ [2]. He suggests that the wide use of smilies indicates that they fill a gap. Whereas writers of person- 1. http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0100- al letters know their respondents this is often not the case 879X2007000600001&lng=en&nrm=iso&tlng=en with the Net, making it an impersonal medium. Cultural preconceptions are sometimes impossible to assess, increasing the possibility of comments being interpreted as personal insults. The smiley, says Quinion, is univer- Erratum sally understood to mean ‘only joking’ and thus avoids embarrassment. I would question this argument. When I The recent article by Shashok and Jacobs published in drive to our local shops I am coerced into behaving TWS [Shashok K and Jacobs A. Who’s watching whose myself by a flashing road sign. If I drive under the speed ethics? Slanted reporting of the medical writer’s role in limit of 50 kilometre per hour the sign radiates a smiley Neuropsychopharmacology-Cyberonics case. The Write face, but go 1 kilometre over the limit and a grimacing Stuff 2007;16(1):33-35] and posted on emoticon with a down turned mouth flashes up. Are the www.emwa.org/Journal.html contained a citation over- traffic authorities ‘only joking’? sight that could confuse readers. The sentence 'Some critics complained, however, that there was no explicit mention of the fact that her fee had been paid by Elise Langdon-Neuner Cyberonics, and insisted stubbornly that the paper had [email protected] been "ghostwritten" [11-14].' should have read 'Some References: critics complained, however, that there was no explicit 1. http://en.wikipedia.org/wiki/Smiley 2. http://www.worldwidewords.org/articles/smiley.htm mention of the fact that her fee had been paid by Cyberonics [11-14], and insisted stubbornly that the paper had been "ghostwritten" [14].' We are grateful to 1 is the tag for an ‘only joking’ smiley in XML. For ways of conveying other emotional tones on a Web page see http://www.geoff-hart.com/resources/1995- Michael Altus for correcting this oversight. 1998/expressive.htm

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Multiple problems: Different or more of the same?

by Alistair Reeves

My first thought many years ago when faced with the term mal leash having a swiveling arrangement in order to multiple-dose study was that groups of subjects received rotate that portion of the leash having multiple lines that different doses. I had to learn that this is not the case, and connect to each of the collars on the animals. A swiveling that this means that subjects receive the same dose repeat- arrangement will prevent the multiple leashes from entan- edly. The term repeated-dose study also exists (which I gling with one another so that more than one dog or other prefer, but do not correct when editing). A Google search animal may be walked with the handler only having to hold will show you that they exist alongside each other and are onto one main leash”. In the context of this description, used with about equal frequency. So here, multiple means multiple lines and multiple leashes sounds acceptable, but more than one of the same, at least in our context. multiple dogs or other animals obviously did not sound acceptable to the authors, because they chose to write more The specific question that stimulated this article was: Is it than one dog or other animal. This would have been exact- possible to say multiple animals? My spontaneous reaction ly my feeling too, and I would also have described the was that this sounds strange, and, after some consideration product as a leash for more than one animal or several ani- and research, I am still of the same opinion. mals, expecting that several of the same animal would be Consult the Wikipedia website multiple marriages [1]: you attached to the leash. Without further explanation, howev- will find Mickey Rooney and Zsa Zsa Gabor with 8 spous- er, it cannot be denied that multiple here suggests that you es in succession, and 4 other people with upwards of 9. might attach a dog, a cat, an iguana, and a hyena to the Why is it that multiple marriages sounds acceptable, but lead, if unlikely. If this really were the intention, then I multiple husbands or multiple wives does not? Or does it? would prefer to call the leash a multiple leash for different If you are talking about bigamy or polygamy, then multiple animals, and would wish the walker lots of fun with that husbands or multiple wives sounds acceptable, but because combination. bigamy and polygamy are generally the exception, the A further website gives advice on the proper transport and mind places its filter on the use of the word multiple sale of multiple animals, and means, for example, trans- together with the word marriages, and these are usually porting herds of sheep, cattle or pigs—so more than one of understood to be successive, unless the context makes the the same type of animal [3]. Of course, it could mean trans- reader think otherwise. This is probably why you are much porting a mixed herd, but herds are not usually mixed. more likely to say she has had several (or numerous or dif- ferent) husbands rather than she has had multiple hus- bands. This illustrates the use of ‘multiple’ very well: it is highly context- and usage-dependent and is frequently col- located with some nouns in some situations, but just does- n’t sound right together with other nouns. And this is not determined by rules or conventions, for example, that mul- tiple as a modifier sounds acceptable with the singular, but not with the plural. Regardless of whether the spouses came in succession or together, multiple as used above also has the dimension: more than one of the same. I appreciate that the spouses may have had different ethnic backgrounds or very differ- ent external appearances, but they were all in the same cat- egory, i.e. spouses. Even though an animal is an animal, whether you are talk- ing about a dog or a gnu, multiple animals on a website that describes the patent for an Animal leash for multiple ani- mals [2] does not sound acceptable: “The invention relates Drawn by Michael Dawes to the field of animal restraints and in particular, to an ani- The new multiple animals were proving to be quite challenging test subjects >>>

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>>> Multiple problems: Different or more of the same? But multiple does often mean different things, and this read …from different patients attending hospital in Brazil. seems to be especially when dealing with abstract con- “Managing dyslipidaemia—multiple patients and multiple cepts. Acceptable (but only just about) is to say We had approaches: metabolic syndrome, familial hypercholes- multiple reasons for rejecting her proposal. I would prefer terolaemia and hypertension”[5], another journal article to say We had several different reasons for rejecting her title. Does this just mean more than one patient, or patients proposal. At a pinch, you might also understand it to mean with dyslipidaemia of different origins? Together with the that there were many different single reasons, or several word approaches, multiple sounds acceptable, because this reasons with more than one element each. means that there are different ways to treat patients with dyslipidaemia, presumably depending on the origin. But mul- What do we assume from the word multiple in the title of tiple patients just does not sound right whereas different this journal article: “Identical Burkholderia cepacia com- approaches for different patients does. plex strain types isolated from multiple patients attending Want a ‘pet portrait? Consult pet.drawings.com [6]. The a hospital in Brazil”[4]? The authors were reporting on website sells pet portraits and offers pictures of multiple more than one clinical source in Brazil. So the use of the animals, illustrating this with, amongst others, a drawing word multiple is actually inappropriate: patients would of a Yorkshire terrier and a dachshund—all the examples suffice, and to reflect the difference the title should have supplied show different animals, sometimes just different dog species, sometimes with cats and other animals. This underlines the fact that multiple is often expected to mean The French caused English different and not just more than one of the same type. But somehow the collocation multiple animals just doesn’t to become the language of work. A house can have multiple entrances, or you can science have multiple options or multiple injuries, but you can’t have multiple drinks or multiple pictures on your walls. In According to a footnote on page 69 of Seth Lloyd’s a multiple-choice question, you have a series of different book Programming the Universe the French Academy answers to choose from, and not multiple answers. of Sciences caused the adoption of the English lan- Probably influenced by the idea of diversity in the word guage as the international language of science in the multiple, a multiple animal conjures up to me the idea of a seventeenth century by being the first national academy Hydra-headed chimera-like creature with the tail of a drag- to abandon the previous international language, Latin, on, the rear end of a horse, the forelegs of a cow, and the and publish their proceedings in their own language. head of a dog, zebra and eagle, or any other combination. The English and Germans just followed suit. The rest is The connotative image with multiple patients is a sort of just an accident of history. Voldemort-Ganesh-Jake-the-peg-like figure, possibly with 2 faces, more than 2 arms, and 3 legs. It seems that multiple generally works when collocated Should medical journalists with inanimate objects, but not with animals or people, and seems to be used more frequently to indicate that the plu- declare conflicts of ral entity consists of different elements. And it is therefore interests? not possible to give easy advice on when to use it best. What can you say if you are tempted to write multiple but Where would we be without journalists? Certainly with- are not sure? Depending on the context, more than one, sev- out a democracy. But what about medical journalists eral, different, numerous, a number of, a few, many, a series who receive ‘free lunches’ from the pharma industry? of, some, various, groups of, a plethora of, and a multitude Should they declare their competing interests? Ben of are all good options. So you have multiple choices-but Goldacre, a medical journalists, asked some colleagues. this doesn’t sound right either (but different does)! He found the range of responses he received striking and reports them in his interesting article in the BMJ [1]: Alistair Reeves “some laughed at my naivety: some expressed outrage at Ascribe Medical Writing and Translation the venality of their colleagues: and some were emotive Wiesbaden, Germany [email protected] and defensive, playing down the idea the there was any- www.ascribe.de thing to worry about and explaining journalists could References: detach themselves from such ties and remain impartial. 1. http://en.wikipedia.org/wiki/List_of_people_with_multiple_marriages In fact the arguments almost exactly mirrored those 2. http://www.patentstorm.us/patents/5901668-description.html among medics, played out in editorials and letters about 3. http://www.crlms.com/Portals/12/WebHelp/Managing_Animal_Locations/Mo- ving_Multiple_Animals.htm conflict of interest in academia, about 15 years ago.” 4. http://jmm.sgmjournals.org/cgi/content/full/55/2/247 5. http://eurheartjsupp.oxfordjournals.org/cgi/reprint/6/suppl_A/A23.pdf Reference: 6. http://www.pet-drawings.com/gallery/multiples0.html 1. Goldacre B. Journalists: anything to declare? BMJ 2007;335:480 All websites were accessed on 3 September 2007.

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4-letter words and others

by Alistair Reeves

Small words can often change meaning dramatically and the assay requires no pre-analytical procedures that resemble cause writers a great deal of bother (not only in English— the addition of protease inhibitors. The pre-analytical step anyone who has learned German or Hebrew will remember could be something quite different—the author just meant the travails of learning how to use ‘je’ (roughly equivalent that the assay has the advantage that it requires no pre-ana- .lytical procedures and wanted to give an example (א ת) ’to ‘each’ in other languages in some contexts) or ‘et (an indicator of the accusative which leads a life of its own). In English, these words are often slipped into sen- Both tences when speaking and are sometimes hardly noticed. Both indicates that you are talking about two things. It is The position when spoken is often not so important; they worth paying attention to the position of both in your sen- sometimes form part of an ‘afterthought’ and are therefore tence. This is usually determined by whether it is used as not in the ‘correct’ position for written English. But it is not an adjective or an adverb. It is definitely a useful device always the position that counts: some are used only in spo- when used as an adjective to convey the idea of ‘two’, but ken language, and some have particular quirks when writ- when used adverbially, it can be argued that it is often ten. I am starting this series with 3 inoffensive 4-letter superfluous, unless it is used for emphasis or to convey the words: till, like and both. idea of uniformity or congruity, and sometimes it may even be superfluous as an adjective too. Till Till when it means until should be reserved for spoken Adjectival use: English or informal use when writing, such as emails. If We saw similar trends in both groups. you are speaking, you might say: Samples should be incu- bated till distinct green spots form on the surface; if you 2 patients dropped out after 8 days of treatment; both men are writing, write: Samples should be incubated until dis- had baseline diastolic levels of 105 mmHg. tinct green spots form on the surface. The position here is clear: before the noun that both modi- fies, as is almost always the case for adjectives in English. Like And the reader already knows that you are talking about In spoken British English and spoken and written US two elements that have already been mentioned. English, ‘like’ is often used where ‘such as’ is still pre- ferred in written British English. This is illustrated very Of course, you could just say: 2 men with baseline diastolic well by the following: Over the past year, copeptin meas- levels of 105 mmHg dropped out after 8 days of treatment, urement has been shown to be useful in a variety of clini- but maybe you want to say both because of what is in the cal indications, including the diagnosis of diabetes next sentence, to gain emphasis, for example. insipidus, and monitoring of sepsis and cardiovascular dis- An interesting variant of both when used adjectivally is the eases like chronic heart failure and myocardial infarction. two, which is also acceptable when writing and not only And the following: Second, the assay requires no extrac- when speaking: We saw similar trends in the two groups. I tion step or other pre-analytical procedures like addition of have not yet found any clear distinguishing features protease inhibitors. between the usage of both and the two in this way. I would The like does not sound ‘right’ in British English. This is be interested to hear whether any readers think there are because like indicates similarity, but the aim here is to give specific situations where one should be given preference examples. In the first sentence above, chronic heart failure over the other. Which would you prefer: The secondary and myocardial infarction are actually being given as objectives of this study are to compare the following examples of defined cardiovascular diseases. between the two treatment groups or The secondary objec- Cardiovascular diseases like chronic heart failure and tives of this study are to compare the following between myocardial infarction may just have symptoms that resem- both treatment groups? Or if it is already obvious to the ble these conditions, but may not actually fall within the reader that we are talking about only two groups, perhaps definition of cardiovascular diseases. In the second sen- the following would suffice: The secondary objectives of tence, the addition of protease inhibitors is an example of this study are to compare the following between treatment a pre-analytical procedure, but the use of like sounds as if groups, and you need neither both or the two. >>>

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>>> 4-letter words and others Adverbial use: the EMEA and the FDA. For example: Initially proposed Initially proposed by the EMEA for yearly updates of by the EMEA for yearly updates of licensed interpandemic licensed interpandemic inactivated influenza vaccines, inactivated influenza vaccines, immunological endpoints immunological endpoints have been proposed for evalua- have been proposed for evaluation of pandemic vaccines tion of pandemic vaccines both by the EMEA and the FDA. both by the EMEA and the FDA, and some national authori- This is a typical example of the wrong positioning of ‘both’ ties in Asia. Here the both indicates that the EMEA and FDA when it is forms part of a prepositional phrase with two are one entity and the national authorities in Asia are another. modifying elements used as an adverbial phrase, and is a I said above that it could be argued that both when used adver- frequent error made by both non-native and native speak- bially is superfluous. This is illustrated by the following: ers of English. Initially proposed by the EMEA … endpoints have been This needs some explanation. By the EMEA and the FDA proposed for evaluation of pandemic vaccines by the is a prepositional phrase because it is introduced by the preposition by. In this sentence, it is also an adverbial phrase EMEA and the FDA or …by both the EMEA and FDA. that modifies the verb have been proposed. In the same way, Do you really need to say both here? The answer is no, for evaluation of pandemic vaccines is both a prepositional unless you wish to achieve emphasis. and adverbial phrase because it is introduced by the preposi- tion for and also modifies have been proposed. Here is an error with both that I frequently see from conti- nental European authors: In summary, this survey demon- If the preposition by applies to both elements (EMEA and strates that airway management using the PLMA and a FDA here), then the both should be after the preposition. It controlled mode of ventilation without muscle relaxants in should read by both the EMEA and (the) FDA, to indicate children is both, effective and safe in the hands of staff- that you regard the EMEA and FDA as separate entities. To grade and trainee anesthesiologists. position the both before the by, you would have to say both by the EMEA and by the FDA to be correct. But the correct Both is never followed by a comma when used in this way. positioning of both avoids using the preposition twice. And, as you see, this also avoids repeating the definite arti- Alistair Reeves cle in this instance. Ascribe Medical Writing and Translation Wiesbaden, Germany What would also make the both before the by correct [email protected] would be a further element governed by the both after by www.ascribe.de

EMWA and the Institute of Alistair was right Clinical Research joint in a prior article symposium announcement Alistair Reeves is right 'prior' is an adjective [TWS 15(2)59]. I recently encountered ‘prior to and following EMWA is delighted to announce a symposium to be incubation’ in a report and changed it to ‘before and after held jointly with the Institute of Clinical Research incubation’. ‘Prior to’ was too long for the tables so the (ICR) on 27th February 2008 in London, UK: author shortened to just ‘prior incubation’, which "Publishing Clinical Trials: Ethics and changed the meaning to an incubation that occurred the Pharmaceutical Industry" before the current incubation rather than something that occurred before the incubation. Why is ‘prior to’ gaining This joint EMWA-ICR symposium will be presented by popularity over ‘before’? Neville Goodman and Martin a panel of experts including medical writers, journal edi- Edwards have the answer1. It is a sign of “turgid bureau- tors, academics and pharmaceutical industry managers. cratic prose, of what the cynical may regard as deliber- Topics will include publication policy, ghostwriting, ate attempts to confuse and obscure by euphemism, of fraud and other ethical issues of publishing clinical trials. Pentagonese and Whitehall-speak”. More information about the symposium and details of how to register will be provided this autumn on the EMWA Elise Langdon-Neuner [email protected] (www.emwa.org) and ICR websites (www.icr-global.org ). 1. Goodman NW, Edwards MB. Medical Writing: A Prescription for Clarity, 3rd 27th February 2008—put the date in your diary now! edition. Cambridge: Cambridge University Press, 2006

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In the Bookstores... Standards on style and guidance on policy for medical journals Iverson C, Christiansen S, for details). The sheer size and level of detail of the manu- Flanagin A, Fontanarosa PB, al sometimes slow efficient consulting. For example, Glass RM, Gregoline B, Lurie SJ, advice on the use of hyphens versus en-dashes for words Meyer HS, Winker MA, Young RK. and numbers is located in different sections of the manual AMA Manual of Style, a Guide for with no cross-referencing. Guidance on some policy issues Authors and Editors, 10th ed. New (for example, acknowledging contributors other than York: Oxford University Press, authors) is also treated in different sections, making some 2007. ISBN 978-0-19-517633-9 of the coverage redundant. (Hardcover). Approximately EUR 40.00, GBP 32.00, USD 55.00. In Chapter 5 on Ethical and legal considerations and 1022 pages. Chapter 6 on Editorial assessment and processing, the authors have done a great job of reporting on the most That’s not a typo—the new edition of the American recent ethical issues and recommendations crafted by, Medical Association Manual of Style (AMA MOS10) has among others, the International Committee of Medical one thousand twenty-two pages, and weighs almost 2 kg. Journal Editors. However, the 290 pages this material adds Especially for researchers, writers, editors and translators to the manual might be more at home in a separate hand- who prepare material for health science journals published book aimed specifically at editors, managing editors and in the USA, this reference work provides detailed guidance others with responsibility for deciding what to publish and in six main areas: Preparing an article for publication, ensuring compliance with the most current professional and ethical guidelines. Style, Terminology, Measurement and quantitation, and Technical information. This last section covers , The Forward notes that the manual “contains everything manuscript editing and proof-reading, publishing terms that a group of editors from the JAMA and Archives fami- and additional resources such as dictionaries, other guides ly of journals believe is essential to produce a manuscript to terminology, style and usage, writing, ethics, peer that is well organized, clear, readable and authoritative” (p. review, , databases, guidelines and profession- v). The writing in the chapters on editorial practices and al organizations. The manual is thorough and authoritative policies, typography, and manuscript editing and proof- (especially on objective elements of technical style such as reading does not always make clear when policies followed units and nomenclature in different medical and scientific at JAMA and the Archives journals are being described to specialties); the content is carefully referenced, and the ref- illustrate one possible approach among many alternatives, erences on all topics are impressively up-to-date. and when the manual is recommending a specific evi- dence-based practice as the most effective solution. Users However, the manual’s main virtue—its comprehensive- should be aware that alternative methods for peer review, ness—may threaten to become its downfall. The last page editorial processing and journal production are used by of the index is numbered 1010 in my copy, and there are 12 many successful journals published inside and outside the preliminary pages not counting the Contents page. I USA. International editors and authors need to be aware of haven’t figured out why the publisher lists the number of certain differences in style rules between the US and the pages as 1032 on their website, but that may be just anoth- UK (AMA MOS10 naturally follows US usage), and as the er of the editorial and production glitches that mar this text reminds readers in several places, the instructions for monumental update of the AMA Manual of Style. In a com- authors of individual journals need to be checked to detect plex project involving many contributors it is hard to keep and comply with alternatives to the AMA MOS10 recom- oversights from proliferating in proportion to the total mendations for manuscript preparation. number of pages. Fortunately for users, the publisher main- tains a list of errata at http://www.us.oup.com/us/compan- Editors of small journals with limited resources must ion.websites/9780195176339/errata/?view=usa, and users choose their priorities for quality control and quality assur- should be sure to download the list and check it for updates ance carefully to stay within their limited budget. These from time to time. users can be forgiven for feeling that AMA MOS10 has overlooked the fact that most journals survive on a much The publisher’s website also has links to other types of use- smaller allotment of resources than JAMA and the Archives ful information about AMA MOS10, including an excerpt family enjoy. Advice on which of the recommendations from the Preface that summarizes the main changes and addi- deserve priority when available resources are limited tions compared to the previous edition, published in 1998 would make the manual more useful to editors and publish- (the “What’s new” link at http://www.us.oup.com/us/ ers of small journals that cannot hope to implement all the companion.websites/9780195176339/whatsnew/?view=usa guidance in the manual. >>>

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>>> In the Bookstores... The index still lacks entries for “author’s editor”, “medical A self-training aid for writer” or “translator”, and these entries are also missing from the updated and expanded Glossary of publishing developing medical writers terms. However, the manual supports recognition of the Mark C. Stuart, editor. The Complete work these professionals do by stating, in section 5.1.2 on Guide to Medical Writing. London: Guest and ghost authors, “[t]o give proper credit to medical Pharmaceutical Press, 2007. ISBN writers and author’s editors, journal editors should require authors to identify all persons who have participated sub- 978-0-85369-667-4 (Paperback). stantially in the writing or editing of the manuscript. GBP 19.95, Approximately EUR Substantial editing and writing assistance should be dis- 29.60. 512 pages. closed to the editor at the time of manuscript submission This book treats medical writing and mentioned in the Acknowledgment” (p. 132). This not as a technical writing and doc- message is reiterated in section 5.2.1 on Acknowledging umentation task performed to support, assistance and contributions of those who are not authors (pp. 140-141), and again in section 5.5.2 on meet the publication and regula- Reporting funding and other support (p. 173). Translation tion needs of the pharmaceutical is mentioned only in connection with secondary publica- industry, but more broadly as any sort of communication in tion (pp. 149-150); it’s a shame translation was not includ- any medium with medical content, whether aimed at spe- ed in the list of “contributions commonly recognized in an cialists or the general public. So the book is not intended as acknowledgment” on p. 140, because many researchers, a reference work for the experienced medical writer, but as aware of their linguistic limitations, prefer to submit a pro- a career change or continuing professional development aid fessionally translated manuscript rather than inflict on for physicians and students who wish to learn how to pre- reviewers and editors a paper composed in their own pare different types of material that contain medical or English. After all, Chapter 5 (section 5.11.5) recognizes that health information. poor writing alone is now considered a legitimate reason to reject a manuscript (p. 265). Whether this policy is fair to The contents are generally well organized, and the main international authors is debatable, but it’s a fact of life. chapters are clearly sign-posted with headings and sub- headings, boxes and checklists, and so are easy navigate. Given the thorough, up-to-date coverage and the well- The front matter consists of a Foreword by Julia Forjanic deserved prestige this reference work has earned over the Klapproth, a preface by the editor Mark Stuart, a note years, it’s an excellent investment, glitches and all, at about about the editor, and a list of contributors and their profes- 40.00 euros. The layout and are more legible sional qualifications (most have a background in pharma- than in the previous edition, and with frequent use navigat- cy). The 22 chapters are divided into 6 sections that cover ing the manual should become easy. Medical writing essentials, Reviews and reports, Medical Now that the book has become so bulky, however, it is journalism and mass media, Medical writing in education, much less easy to consult on a cluttered desk top than pre- Medical writing for medical professionals, and Medical vious editions were. So the time has come for publication publishing. Cross-references here and there refer readers to in a fully searchable electronic format, and the Preface sections in different chapters that pick up on specific top- ends with an invitation to sign up at http://www.amamanu- ics and develop them more fully. Five appendixes provide alofsytle.com for news of progress on the electronic edi- partial lists of Common medical abbreviations, tion. It would be helpful meanwhile to incorporate thumb Measurements, Normal values for common laboratory indexes or tabs to allow users to quickly access the start of tests, Proof correction marks, and an A to Z of medical each chapter, where the first pages list the contents down to terms in plain English. The index seems complete and the lowest level of subheading. This information, missing detailed, and checking the number of pages indexed for from the Table of Contents, is a substantial aid to naviga- certain entries will give browsers a good idea of how well tion and should be easy to access without having to fold the topics that interest them are covered. down page corners or add makeshift sticky-note tabs. Each of the six sections contains some outstanding chap- ters and many solid contributions. The stand-outs are Chapter 7 on Conference posters (how to design them, how Publication to prepare the all-important 1-minute introduction, and how to ensure that your poster earns attention and con- transparency survey tacts), Chapter 10 on Writing for magazines and newspa- Medical writers are asked to take part in the ‘PPP’ sur- pers (equally useful for freelancers, in-house writers and vey [see TWS 16(2) p92], which can now be accessed academics), Chapter 14 on Presentation materials (i.e., slide shows), Chapter 18 on Writing marketing authoriza- via EMWA’s website at http://www.emwa.org/MEM- tion applications for medical products (featuring a detailed BERS/InDevelopment/PPPSurvey.htm or directly at anatomy of the Common Technical Document) and http://www.zoomerang.com/recipient/survey-intro.- Chapter 21 on Writing for the internet (an excellent intro- zgi?p=WEB226SPGYXRDX duction to website quality and usability, with good advice

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In the Bookstores... about discussion forums, email, blogging, wikis and news edition of a new book on a complex subject can’t be all items). Of the 22 chapters only one or two seem to be in things for all readers, and despite these minor oversights in need of major reworking for the next edition. user-friendliness, Mark Stuart has done an excellent job of There is a slight degree of overlap between the first two assembling, organizing and editing a large number of indi- chapters (both on writing effectively), and it would have vidual contributions into a coherent resource that covers been preferable to attribute Chapter 2 to named authors most of the fundamentals very well. rather than to the “Plain English Campaign”. But that’s a Although not quite the “complete guide” its title claims it quibble given that the book misses few opportunities to to be, the book is a useful addition to the writer’s collection remind readers that plain, simple language is most effec- of reference and professional development aids, especially tive, and also notes that scientific writing is likely to have if the writer plans to work for clients and audiences in the many readers for whom English is not the first language— UK. Apprentice medical writers who buy it should comple- another good reason for writers to aim for plain English. ment the valuable advice in this book by consulting other Chapter 5, mis-titled “Reviews”, deals with other types of resources [1-4], and by visiting the websites of the research methods and reporting formats in addition to International Committee of Medical Journal Editors reviews, and contains valuable information that would ben- (http://www.icmje.org), the CONSORT Statement efit from re-organization to cover clinical and basic research (http://www.consort-statement.org) and the Good methods, hierarchies of evidence, types of study design and Publication Practice for pharmaceutical companies their corresponding research report formats, and types of (http://www.gpp-guidelines.org). For effective training, review. This chapter, regrettably, has no references. While however, nothing beats attendance at courses designed by we await a revised edition users of the book can obtain fuller professionals for their peers; EMWA’s training courses information on different types of and report- deal with specific aspects of medical writing in greater ing formats from the excellent on-line resources made avail- depth and detail than is available in “The Complete Guide able by the BMJ at the Checklists & Forms link at to Medical Writing”. http://resources.bmj.com/bmj/authors/checklists-forms. Parts of chapters 8 and 9 might have been more appropri- Karen Shashok Translator—Editorial consultant ate in the section on reviews and reporting formats rather Granada, Spain than and the mass media. Chapter 13, [email protected] on Writing examination and assessment papers, is probably References: more useful to academics and university-level instructors 1. Albert T. The A-Z of medical writing. London: BMJ Books, 2000. 2. Godlee F, Jefferson T (editors). Peer review in health sciences, 2nd edition. than to medical writers. London: BMJ Books, 2003. 3. Goodman NW, Edwards MB. Medical Writing: A Prescription for Clarity, 3rd Referencing is very uneven across chapters, some ending edition. Cambridge: Cambridge University Press, 2006. with more or less complete lists of works the authors con- 4. Wager E. Getting research published. An A to Z of publication strategy. sulted, but some providing no references at all. The Oxford: Radcliffe Publishing, 2005. >>> Appendixes are rather sketchy, and because the criteria used to decide what to include and what to leave out are unclear, they are not as authoritative or useful as the main chapters. It would probably be faster and more reliable for the writer at work to check the specifics of abbreviations, units, laboratory values or terminology on the Internet or in specialized style guides. The index does a good job of tak- ing readers to where they can find information on specific Call for articles topics. For a book like this one—which makes generous for TWS’s use of headings and subheading—readers would also find December it useful to see all the headings in each chapter listed in the Table of Contents. issue Appropriate authorship, public credit for medical writing The theme for the December services, appropriate citation of sources, plagiarism and 2007 issue of TWS is ‘titles’ as biases in research publication are issues faced frequently in book or article titles, as well by many of those who assist others in communicating med- as academic titles. Articles photo: Marlies Kari Neuner ical and health information. So it might have been helpful (800-2800 words) or boxes (up to 800 words) on this to gather ethical issues together in a separate chapter and topic are welcome and should be submitted by 12 cover them in a bit more depth. Open access and electron- November 2007 to Elise at [email protected]. TWS is ic publication, now part of life, might also have been cov- always happy to receive articles or boxes on any topics ered more fully. The list of professional organizations of interest to medical writers and suggestions for future (including EMWA) at the end of the last chapter might themes. have been more noticeable as an Appendix. But the first

The Journal of the European Medical Writers Association 128 Vol. 16, No. 3, 2007 TheWrite Stuff

>>> In the Bookstores... A book to squeeze into the gaps than slashes when there are more than two units, e.g. 40mU • m-2 • min-1 rather than 40mU/m2/min. Now I know on a medical writer’s bookshelf that three slashes are ambiguous whereas two are not—and Matthew Stevens. Subtleties of why. Interesting thoughts are also slipped in, for instance Scientific Style, ScienceScape the suggestion that pleonasm (where one word is implied Editing, 2007. ISBN 0-9578877-2-8 by another) is so common in English because of the influ- (paperback). USD 12 (approximate- ence of Norman French on the (British) court system. ly EUR 8.84, GBP 6.00), 112 pages. Terms were duplicated in both languages to ensure that English speakers and French speakers understood, e.g. The book can be ordered or down- ‘null and void’, ‘terms and conditions’. loaded as a pdf (for USD 6) through http://www.zeta.org.au/~mls/ Generally, concepts in the book are exceptionally well subtleties.html. explained and supported with clear examples. One of my favourites is ‘Stacked nouns and adjectives’. An example used Subtleties of Scientific Style has been written for language in this section gives a taste of Steven’s clear writing style: editors. It is about subtle recurring writing errors, other Two words: “bank rate”. That’s easy enough. Three: books cover the common errors. The author decided to “bank rate rise”. That’s a rise in bank rates. Four: “bank write the book when he realized that the books on his rate rise leak”. Now that’s getting harder. Five “bank shelves did not deal adequately with faults in writing that rate rise leak probe”. What’s that? To get the answer we he regularly encountered. actually have to read it backwards: a probe (investiga- Matthew Stevens opens his book by telling us about him- tion) into the leak of a rise in bank rates. self and about his book. He is Australian and he warns that Danglers are explained as a phrase that has become he finds much US usage of English perplexing, if not orphaned and is in need of a subject but is forced to make wrong. Part of the problem of science editing, he suggests, do with the nearest it can find. The result is that the con- is that usages have become ingrained into the language of nection between the phrase and the thing it refers to is lost. science and no one really thinks about what they really ‘Times’ and ‘fold’ are very often used incorrectly. Stevens mean any more. Readers are invited to send him any explains the use of these words so well that it would be favourite subtlety that he has not covered and they would hard for anyone to come away failing to understand the dif- ference between ‘times large than’ and ‘times the size of’. like to see covered in a later—and bigger—edition. There are a couple of points which have insufficient expla- The next introductory section asks: What is science? The nations. ‘Studies on/of’ is dismissed with ‘Prefer studies main force of this section is that science does not happen of’. As nearly every report that crosses my desk now is a but is done by people. Therefore authors should be honest ‘Study on’ and I intuitively change this to ‘Studies of’ it is about this and not tortuously avoid the active voice. The comforting to know that Stevens would make the same body of the book is written under the following headings: change but it would be even nicer to know his reasons. Substantive editing, Common errors, Errors of substance and sequence, Errors of reasoning, Improving expression, Stevens clearly believes in straightforward honest writing. Improving visual presentation, Tricky or misused terms, So I was surprise that after advising against writing “ ‘sac- rificed’ because it comes too close to being euphemistic, he and Errors in classical languages. There are five appen- suggests that ‘euthanase’ can be used instead because it dices: Editing techniques, Wordy phrases, British or US means a good death and this is an accurate description of spelling?, Unicode values and non-displaying characters, how laboratory animals are killed. I cannot agree with and Character charts in logical groupings, which the author Stevens here. If anything is euphemistic it’s the application describes as two handy character charts for Macintosh- and of ‘euthanasia’ to laboratory animals. Euthanasia is a Greek Windows-based editors who are tired of hunting around for word meaning good death. But the current meaning goes special characters. The book ends with a bibliography of beyond this1. It means a merciful death of a person suffer- Books, Worldwide Web resources and Software. ing from a terminal illness or an incurable condition. Even if you were to extend the definition to animals the word cer- When I first started editing I read many books about edit- tainly does not imply that the person killing caused the con- ing. Nowadays I often lack the enthusiasm to read a new dition (which would hardly be merciful) or, which is often book because I have already read what new books have to the case, that laboratory animals are killed because they are say in an old book. This book is different. I learnt some no longer of any used and it is inconvenient to keep them2. answers to questions which my previous reading had never This book weighs only 250 g and would be worth squeez- answered. For example the journal I used to edit required ing onto the bookshelf between such tomes as the 2-kilo me to change rpm (revolutions per minute) to g (gravity) AMA Manual of Style. when centrifugation was being described. I have now been enlightened as to why this change should be made and why ‘g’ should be in italics (to avoid confusion with grams). Elise Langdon-Neuner Vienna, Austria Another style requirement was the use of exponents rather [email protected]

1 See for example www.answers.com/topic/euthanasia?cat=biz-fin and www.medterms.com/script/main/art.asp?articlekey=7365 2 Buyukmihci N.C. Ethical and practical Concerns for the Use of Nonhuman Animals in Research http://avar.org/pdf/publication/paper/research.pdf

129 The Journal of the European Medical Writers Association TheWrite Stuff Vol. 16, No. 3, 2007

Webscout:

Alternative and complementary therapies

by Joeyn Flauaus

For almost all readers of The Write Stuff, writing about con- http://www.chiropractic-uk.co.uk ventional methods of diagnosing or treating diseases is Chiropractic is an alternative medical approach to manag- daily business. Wouldn’t it be interesting to look at the ing conditions that are due to problems with the joints, lig- other side of the fence to explore the world of complemen- aments, tendons and nerves of the body, particularly those tary and alternative therapies (CATs)? Which CATs are of the spine. Chiropractic uses a type of hands-on therapy popular at the moment? Are they effective? called spinal manipulation or adjustment to activate the self-healing abilities. The aim is to improve the function of In general, CATs comprise therapies used instead of, or in the joints, relieve pain and muscle spasm without the use of addition to, conventional and traditional medical treat- medication. ments. CAT practices are often based on belief systems that are at odds with the findings of science. They often use http://www.quackwatch.com spiritual, metaphysical, untested and innovative methods Quackwatch—Your Guide to Quackery and Health Fraud. of treatment and healing. CATs are sometimes adopted by If you are concerned about the benefits and the efficacy of conventional practitioners and no longer considered alter- alternative therapies or you simply want to know why native if they have demonstrated to be safe and effective ‘unconventional’ therapies seem to work visit this page. (e.g., acupuncture). If you find a page or a blog that should be mentioned in the next issue, or if you have any other comments or sugges- Below you find a selection of websites introducing you to tions, please email me at: [email protected]. some CATs and a website analysing the benefits and scien- tific evidence of efficacy (or lack thereof) of the CATs. Judge for yourself! Joeyn M. Flauaus Trilogy Writing & Consulting GmbH Frankfurt am Main, Germany http://www.thrive.org.uk “Thrive” is a British charity that makes use of gardening to change the lives of disabled people. The healing aspects of gardening are being used as a therapy or as an adjunct to therapy. Garden therapy (or social and therapeutic horticul- ture) programmes result in increased self-esteem and self- confidence of participants by developing social and work- ing skills, literacy and numeric skills, the development of Goggling and Word tips responsibility etc. People recovering from a major illness A colleague translates crime novels from English into or injury (e.g. stroke patients, car accident victims) or hav- German in her spare time. Sometimes she asks me about ing mental health problems can benefit from the therapeu- English words. The last question was, ‘What exactly is a tic aspects of gardening as traditional forms of communi- twisted wire chair?’, Goggle had not been much help. Had cation are not necessarily required. she tried Goggle Images? We did this and found enough pictures for her to write a description in German. http://www.createwritenow.com Almost as a matter of course when I am writing some- Writing therapy uses the process of writing for inner explo- thing I use the right mouse to check synonyms in Word in ration. Writing about your feelings aims to gradually ease case there is a better word which did not immediately pain and to strengthen your immune system. Writing ther- come to mind. This produced nothing for ‘tongue-in- apy can take place with a therapist or through mailing or cheek’. Neither did my paperback Roget’s Thesaurus. Put the Internet. Writing therapy targets patients who deal with the phrase into Goggle followed by ‘synonym’ and numer- mental and physical illnesses. This special kind of therapy ous resources pop up, providing alternative choices. is attractive for patients who prefer an anonymous setting as they don’t need to expose their private thoughts and anx- Elise Langdon-Neuner ieties in person. [email protected]

The Journal of the European Medical Writers Association 130 Vol. 16, No. 3, 2007 TheWrite Stuff

Journal watch:

Authorship guidelines and ghostwriting, and using multiple publications to improve the reception of a single research study

by Melanie Lee

Ghost marketing Medical journal guidelines on authorship The use of ghostwriters and ghost authors by the pharma- Guidance for determining authorship is available from a ceutical industry has again been heavily criticised, this number of organisations including the Committee on time in an article by Barton Moffat and Carl Elliot from Publication Ethics [2], the Council of Science Editors [3], the Center for Bioethics at the University of Minnesota and the International Committee of Medical Journal [1]. The article begins by giving an overview of ghostwrit- Editors (ICMJE), which publishes the Uniform ing and goes on to discuss the types and prevalence of Requirements for Manuscripts Submitted to Biomedical ghostwriting, arguments against ghostwriting, how sci- Journals (URM) [4]. Despite this there are currently no ence is undermined by ghostwriting, and why ghostwrit- universally accepted criteria for determining authorship. A recent study of industry sponsored trials found evidence of ing persists and how it can be eradicated. The authors ghost authorship in 75% of papers [5]. Publications con- describe how pharmaceutical companies contract medical sultant Liz Wager has surveyed the guidance for authorship communications agencies to prepare articles and then given by biomedical journals and assessed whether the commission an academic physician or researcher to advice is consistent between journals and/or complies with ‘author’ the paper—the ghostwriter ‘will typically pro- international guidelines. The results have now been pub- duce an initial draft of the article, specified to order by the lished in an article on Medscape [6]. Instructions from pharmaceutical company, which the academic sham 234 journals were reviewed, including 9 journals edited by author is then invited to review, revise, or simply to sign’. ICMJE members, 117 journals edited by members of the Whilst it is true that a medical writer usually prepares the World Association of Medical Editors (WAME), and initial outline for a paper, the authors will generally 108 journals edited by non-WAME editors. Nearly half of review the article at least once. During the review process the journals (100 journals, 41%) did not give any guidance there should be adequate opportunity for a full discussion on authorship. Journals edited by WAME members were of the accuracy of the results presented and the conclu- significantly more likely to mention authorship in their sions made. The authors of the manuscript retain control instructions (82/117 or 70%) compared with journals edit- over and are responsible for the data presented and the key ed by non-WAME members (43/108 or 40%) (chi-square messages and conclusions put forward. The medical writer test, p < 0.001). Of the 134 journals (59%) that did mention ensures the clarity and readability of the paper, and facili- authorship, 68 (29%) based their guidance on the ICMJE tates the integration of the opinions of several authors. criteria, 26 (11%) included a general reference or link to Moffat and Elliot also state that ‘when articles appear in the ICMJE web site, 25 (11%) included direct quotations press, the academic appears as the author, while the con- from the ICMJE authorship guidance, and 17 (7%) con- tributions of the ghostwriter and the pharmaceutical com- tained paraphrased versions of the ICMJE criteria. Of the journals that cited the ICMJE URM, 35% referred to an out pany remain hidden’. While EMWA guidelines recom- of date version. 33 (14%) journals proposed their own cri- mend the acknowledgement the medical writer and disclo- teria for authorship, and 33 (14%) journals stated only that sure of their funding source, it is still not common for all authors must approve the final version of the submitted these details to be included at the end of a journal article. manuscript. A limit on the number of authors who could be Adhering to these recommendations would address some listed was set by 8 (3%) journals. Only 21 (9%) journals of the issues of ghost authorship for many people, whilst required listing of individuals’ contributions to a project others may argue that the role of a sponsor and/or gifts and their names and affiliations. This survey has shown given to author(s) from a sponsor should also be revealed. that the guidance provided by journals about authorship However, Moffat and Elliot are highly critical of ghostwrit- still varies greatly. By adopting more uniform policies, ing and argue that it is ethically wrong. They propose that a journal editors could play an important role in ensuring that task force should be established to gather information about authorship is accurate, equitable, and transparent, thereby potential cases of ghostwriting, and that authors found to be helping to avoid authorship abuses such as the use of unac- involved should be sanctioned. knowledged ghostwriters or guest authors.

131 The Journal of the European Medical Writers Association TheWrite Stuff Vol. 16, No. 3, 2007

Journal watch:

Multiple publications improve the reception of a single research study The practice of repetitive publication (republication of an Appealing ideas entire paper or closely similar versions reporting the same from other languages body of research) and divided publication (breaking down English has a vast vocabulary but other languages can of findings from a single piece of research into a string of express some good ideas better: papers, each of which is the ‘least publishable unit’) is sur- Kopuhia = someone who disappears instead of dedicat- prisingly common. In a survey of 3,247 scientists, approx- ing himself to his work (Rapa Nui, Easter Island) imately 5% reported that they had published the same data Linti = someone who idles his day away lying under a in 2 or more publications within the previous 3 years [7, 8]. tree (Persian) It has been estimated that the occurrence rate of repetitive Zamzama = to waft along in a relaxed style (Arabic) papers in the clinical medical literature may be 0.017–303 Goyang kaki = relaxing and enjoying oneself as prob- repetitive papers per 1,000 papers published [9, 10]. Lutz lems are sorted out by others (Indonesian) Bornmann has recently investigated whether the practice Bettschwere = without the energy to get out of bed of ‘multiple publication’ actually leads to greater reception (German) of the research [11]. Data from 96 applicants for a research Nubie yam = a farmer who points to his farm but does fellowship from the Boehringer Ingelheim Fonds (BIF) little more, i.e. finger farm (Waali, Ghana) were used in the analysis. Participants listed all the articles Gober les mouches = to stand by and idly gulp down they had published in the framework of the research proj- flies (French) ect for which they had applied for a BIF grant. The recep- Source: The Meaning of Tingo by Adam Jacot de Boinid, Penguin Books 2005 tion of articles by scientific peers was measured by citation counts, as this is a generally accepted measure of the impact of scientific research. The total number of citations was found to increase approximately linearly with the Where do doctors get number of papers published on a study, and this increase information? was dependent on the mean number of pages in the articles. A recent review of the literature found that doctors still Therefore, publishing more articles resulted in higher cita- rely on paper and personal communication as their prime tion counts of the articles, providing the articles had source of information. The article considered the infor- enough content to gain citation by other researchers. So it mation needs of doctors, the way in which they seek does pay to publish multiple articles for a study in the form information and the sources they use. of sizeable reports. Davies K. The information-seeking behaviour of doc- tors: a review of the evidence. Health Information and Melanie Lee Libraries Journal 2007;24(2):78-94. Dianthus Medical Limited http://www.blackwell-synergy.com/doi/abs/ [email protected] 10.1111/j.1471-1842.2007.00713.x References: 1. Moffat B and Elliot C. Pharmaceutical companies and ghostwritten journal articles. Perspectives in Biology and Medicine 2007;50(1):18 –31. 2. Albert T and Wager E. How to handle authorship disputes: a guide for new researchers. COPE Report 2003, Committee on Publication Ethics, London. Available at: www.publicationethics.org.uk. 3. Council of Science Editors. Who’s the Author? Problems with Biomedical Authorship, and Some Possible Solutions. Available at: http://www.coun- cilscienceeditors.org/publications/v22n4p111-119.pdf. 4. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Available at: www.icmje.org. 5. Gotzsche PC, Hrobjartsson A, Johansen HK, et al. Ghost authorship in indus- try-initiated randomised trials. PloS Med 2007;4(1):e19. doi:10.1371/journal.pmed.0040019.6. 6. Wager E. Do Medical Journals Provide Clear and Consistent Guidelines on Authorship? Medscape General Medicine 2007;9(3):16. Available at: Competition in December’s TWS http://www.medscape.com/viewarticle/558094. Meet Alexander Pope, Blue, Sporty, Ginger, Zoe, Bono, 7. Martinson BC, Anderson MS and de Vries R. Scientists behaving badly. Nature 2005;435(7043):737–8. Jacques, Nutte and many others in the next issue! TWS 8. Wadman M. One in three scientists confesses to having sinned. will be holding a challenging (and fun) competition in Nature 2005;435(7043):718–9. the December issue. The task will be to match author 9. Huth EJ. Irresponsible authorship and wasteful publication. Annals of Internal Medicine 1986;104(2):257–9. photos of regular contributors to photos of their pets. 10. Schein M and Paladugu R. Redundant surgical publications: Tip of the ice- The prize will be a free ticket to the banquet at EMWA’s berg? Surgery 2001;129(6):655–61. 11. Bornmann L. Multiple publication on a single research study: does it pay? The Spring Conference in Barcelona. influence of number of research articles on total citation counts in biomedi- This picture is reproduced with the kind permission of Rosebuds of Haworth cine. J American Society for Information Science and Technology who sell a range of decorative products for the home (www.rosebudsofhaworth.com). 2007;58(8):1100–7.

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Hey, it’s only my opinion

Impact factor manipulation

by Diana Epstein

In the early 1960s Irving H. Sher and Eugene Garfield cre- stop a journal from manipulating its IF was the editor’s ated the Science Citation Index for peer reviewed scientif- own integrity. The ‘impact game’ may be played in a num- ic journals. They realised that if journals were selected for ber of ways [3] as set out in the paragraphs below. the index solely based on total publications or citation • Self-citation. Self-citation refers to a paper being counts small journals which specialise in certain topics submitted to a specific journal in which papers that may not qualify for inclusion, which would be unfair. So have been published during the previous 2 years in they came up with a simple calculation for journal selec- that same journal are cited in the reference list. While tion: the number of citations a journal receives in a given self-citation of relevant papers is legitimate, exces- year to all articles published in the previous two years sive self-citation can indicate a manipulation. divided by the number of substantive articles the journal Thomson Scientific, the company which now lists published in those previous two years = the journal impact factors, considers self-citation to be (IF) [1]. The Box on the next page gives an example of an acceptable up to a rate of 20%, anything over that is impact factor calculation. considered suspect. The IF is currently used not only to measure a journal’s sci- High self-citation rates may not always be unethical. entific influence but has become increasingly important as They can arise because the journal provides a unique a basis for awards of research funding, grants, and authors’ publication forum for a new or specific topic or academic advancement—a development which has been because the journal receives a low number of cita- heavily criticised1. tions and few incoming citations from other journals. Every year a discussion is held at one of the journals I man- For such small journals a small increase in self-cita- age to agree a topic for the annual editorial. Last year there tions causes a large shift in its IF. However, an uneth- was a slight drop in the journal’s IF and we decided to ical editorial practice that encourages authors to add address the impact factor. First we compared the current citations to papers from the journal to the reference ranking with rankings of previous years. While doing so list or remove citations from competing journals with we noticed that there were two other journals in our jour- a view to bumping up the journal’s IF can lead to a nal’s subject classification which had mysteriously distorted view of the journal’s participation [4]. increased their ranking within one year, causing our rank- • Increasing non-source items in the journal. Not all ing to drop. We investigated further and brought to light a articles published in a journal qualify as substantive serious manipulation of these journals’ impact factors, source articles for inclusion in the denominator of the brought about by self-citation. One journal’s IF was boost- IF ratio calculation—but all citations of these non- ed 18 ranks by one paper containing 303 self-citations. source articles are eligible for inclusion in the numera- Both journals involved were given a severe warning and tor. A more subtle manipulation is therefore to include the next IFs published in June 2007 showed a decrease in articles in the journal that do not count as source items their ranking. The editorial addressing the IF, which should for the denominator. It is not always clear how have been published in our January issue, did not appear in Thomson Scientific distinguish source from non- print until the July issue. Competitor publishers, editors in source articles but a general guide is given in Table 1. chief and societies did all they could to block publication Interestingly the ratio of pages in Nature devoted to of our editorial. Under this pressure it was carefully rewrit- ten and eventually turned into a position statement on Table 1: Types of articles counted and not counted as source items impact factors from one of the societies affiliated with the Counted Not counted journal [2].The political ramification of our discovery was immense and even today the seismic sensations are being Original Papers Editorials Review articles Letters to the editor felt in certain learned scientific societies. Case Reports News items How easy is it to manipulate the IF? Amazingly, it is Proceedings papers Abstracts Short reports (communications) Commentaries incredibly easy. Indeed all that we came up with that might

1 The European Association of Science Editors (EASE) has posted a draft statement of its stand point on the inappropriate use of the impact factor on its website www.ease.org.uk. The statement recommends that journal impact factors are used only—and cautiously—for measuring the value of journals.

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Hey, it’s only my opinion

source to those devoted to non-source material more More ways editors can than halved from 3:5 in 1977 to 1:6 in 1997, while improve impact factors the number of pages in the journal remained about the same. The 17 March 2007 issue of BMJ with its theme ‘Finding your way around the impact factor’ is a useful • Review articles. Another strategy for increasing IFs resource for finding out more about current thinking on is to publish as many review articles as possible the impact factor. because they are more likely to be cited. Hence, jour- One delightful banter is Christopher Martyn’s ‘Advice nals that only publish review articles generally have to a new editor’ in which, posing as an experienced edi- high impact factors. tor, he writes a letter to a colleague who is about to take • Timing. The timing of publication can also affect the over the reins as the new editor of a journal. He warns IF. Considering the sample period of 2 years, a good that the first thing potential authors will ask her about the journal will be “What’s the impact factor?” Forget all paper published in January has 11 months longer to be your good intentions about serving readers and improving cited than one published in December of the same year! quality it’s raising the journal’s impact factor that an edi- Fortunately, the majority of journals do not use these ques- tor needs to concentrate on. In which way can enterpris- tionable ways to bump up their IF but in subspecialties ing editors increase citations to papers in their journal? where there are a limited number of journals which do not Write an introductory article under the title ‘Editor’s overlap they may be vulnerable. choice’ making a few banal remarks about the articles in Are there legitimate steps that journals can take to increase the issue and—give citations to these articles their IF, by increasing the content of review articles, jug- Commission commentaries on articles in the issue— gling their non-source:source content, asking authors to which cite the articles cite relevant articles from their journal? Are all these prac- Encourage correspondence about articles in the jour- tices fair in love and war in the impact factor game? Could nal—which cite the articles a better manipulation-proof way be devised to rank jour- nals? I am not so sure but until a better way is found I do Publish papers in a well-researched area that contain a believe we are stuck with it and the manipulation debate. serious mistake—people will refer to it in their papers, After all we all like numbers! write refutations and cite the articles. What editors should certainly not do is become social But, hey it’s only my opinion minded and publish papers on unfashionable conditions (e.g. itching) with little research being undertaken and few Diana Epstein researchers to cite it in their publications or case reports Di-Ep Biomedical Editorial Services Ltd. which might be popular with readers but are rarely cited. Glasgow, Scotland, UK

References: 1. Garfield E (2005). The agony and the ecstasy-the history and meaning of the Elise Langdon-Neuner [email protected] journal impact factor. http://garfield.library.upenn.edu/papers/jifchicago2005.pdf (accessed 2 September 2006) 2. Kirchhof B, Bornfeld N, Grehn F. The delicate topic of the impact factor Graefe’s Arch Clin Exp Ophthalmol 2007. 245: 925-927 3. The PLoS Medicine Editors (2006). The impact factor game. PLoS Med Risky business 3(6):e291 DOI 10.1371/journal.pmed.0030291 4. McVeigh ME (2002) Journal self-citation in the Journal Citation Reports- At-risk patients should be screened monthly. Is it really Science Edition (2002): a citation study from Thomson ISI. http://www.isinet.com/media/presentrep/essayspdf/selfcitationsinjcr.pdf necessary to say at-risk here? Patients at risk should be … is OK, of course. But many writers do not seem to be able to resist adding ‘at-’ when they use risk adjectival- ly as a modifier before patient. Risk on its own seemed to do us very well until about the mid-1990s (Risk patients should be screened monthly); and also: the same writers do not seem to need to talk about at-risk groups, but seem happy to use just risk groups. Health econo- mists have tried to tell me that this is a technical term in their area (but why should patients be accorded an at and groups not?). I suspect this is yet another example of the insidious spread of a term we do not need. Or can any- one give me a cogent explanation of the difference between a risk patient and an at-risk patient?

Alistair Reeves [email protected]

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Out on our own: forward. We aim to tackle issues that interest and concern From freelancers for us all and also hope to encourage you to share your expe- freelancers riences. We kick-start our feature section with what we hope will become the first articles of many contributing to Following the successful and dynamic Freelance a valuable freelance information resource. Business Forum at the EMWA conference in Vienna (May This is your section—written by freelancers for free- 2007), we heard your calls for improved communication lancers, so please send us your comments, ideas and con- and information sharing for our membership group. tributions for future issues. Together, let’s make our fea- ture a success. Welcome to The Write Stuff’s first regular dedicated feature section for the freelance membership. Alistair Reeves [email protected] and ‘Out on our own’ will feature in every issue of TWS going Sam Hamilton [email protected]

Presenting freelance support for the freelance membership…

By Sam Hamilton

A consensus was reached by members attending the how much you will charge. Consult the EMWA 2003 Freelance Forum in Vienna, May 2007, that freelance and 2007 Freelance Business Surveys (this issue of advice and support from the more experienced EMWA TWS has a summary of the 2007 results and detailed freelancers would be of benefit to the freelance member- results for both are available to EMWA members on ship as a whole. As a result, a small team of experienced the website). Decide how much you need to earn and freelancers (Sam Hamilton, Alistair Reeves, Linda Lieu, how much work you need to undertake each month to Helen Kulesza and Elaine O’Prey) has developed the fol- achieve this. Determine how you will generate busi- lowing advice lists for consideration by freelance medical ness. Consider the initial equipment costs for your writers when setting up a freelance enterprise and for gen- business. It is especially important that you have eral business conduct thereafter. While most points will some idea of your income and expenditure as well as apply to work in any (EU) country, specific web addresses earning potential if you decide to set up a business or sources of information are given for the UK and bank account (see later) as these are the kinds of Germany, as these two countries have the largest member- questions the bank may ask you. Pension schemes ship groups in EMWA. This is just a start for what we hope and health insurance organisations will also need this will become a valuable resource for new freelancers (also information. on the web page), and we would encourage freelancers 3. Consider if you should trade under your own name or everywhere to add to these addresses or sources of infor- a company name. Determine the legal requirements mation from their own countries, and advise us if there are in your country via the tax office (in the UK: any other country-specific matters that should be included. http://customs.hmrc.gov.uk, in Germany: Please contact Sam with your contributions. http://www.finanzamt.de, which will take you to the The team has also prepared a specific list of points for Finanzverwaltung for your state), a solicitor or small inclusion in freelance medical writers’ agreements or con- business advisor. tracts, which appears at the end of the article. 4. Consider the need for a logo, business cards, a com- Advice list relating to the setting up of a freelance pany image, business stationery etc. enterprise and for general business conduct thereafter 5. Investigate local funding options for setting up your 1. Talk to friends and ex-colleagues about your plans. If business. You may be entitled to loans or grants, so you know any freelancers, ask them how they con- investigate possibilities via the small business advi- duct business, how these activities work, and what sor, Business Link in the UK http://www.busi- important advice they have for someone starting out. nesslink.gov.uk/bdotg/action/layer?topicId=10738611 2. Develop a business plan (you might not think this is 97&tc=000KW020210764, or via the Arbeitsamt or necessary, but it is a very good exercise). Consider Industrie- und Handelskammer in Germany.

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Presenting freelance support for the freelance membership…

6. Contact your local tax office as they often run free account are much higher than in the UK, and busi- courses to help you understand the tax implications of ness bank accounts are very costly, so a second cur- being self-employed (this is certainly the case in the rent account is usually quite adequate. Investigate all UK), or will offer advice on an individual basis. options and deals available. Decide how you will use Business Link in the UK may also be available to your business account. You may choose to pay your- help you establish your business, and often offer free self a set amount each month and keep some in a sep- or subsidised courses. Contact the Arbeitsamt or arate account for your tax bill, etc. Try to use your Industrie- und Handelskammer in Germany for this business (or perhaps a separate current) account so type of information. that you can easily identify all business expenditure. This simplifies year-end accounting. 7. Decide whether you want to hire office or work from home. Consider all the implications of having a 12. Engage the services of an accountant and maintain ‘home office’ because this can often mean that you your book-keeping on an ongoing basis. Advice from never ‘leave work’ even on a weekend (list out the a tax advisor when you submit your annual account pros and cons, and discuss this with your partner if to the authorities can ensure that you claim for all the you have one). If you are short of space at home, then business expenses you are entitled to. Your local tax renting office space might provide a better option. office may also offer to go through your tax form with you and offer advice on what you can and can- 8. Consider the need to be Value Added Tax (VAT) reg- not claim for, or offset against your tax bill. istered. You should investigate the rules governing the charging of VAT, as in the EU, VAT is not usually 13. In some countries, bear in mind that after your first chargeable for clients based outside your own country tax declaration you will be required to pay income (this applies to editing, writing and translation, but tax and VAT in advance. not to training, although there is some variation in 14. Once you decide to become a freelancer, make it a how the EU VAT legislation is interpreted from coun- basic principle to keep every receipt you receive and try to country). Your own country’s VAT rules should keep a written record of every car journey. Many be reviewed. (UK VAT site: items and business travel are tax deductible, saving http://customs.hmrc.gov.uk/channelsPortalWebApp/ch you income tax and VAT. annelsPortalWebApp.portal?_nfpb=true&_pageLabel =pageVAT_Home, Germany: contact your local 15. Consult the EMWA list of points for inclusion in free- Finanzamt or Steuerberater). If you are not sure lance medical writers’ agreements or contracts when about whether you should charge VAT or not, you setting up or reviewing contracts. If you do not use must seek advice from a tax advisor. written contracts, always ask your client to confirm the essential points of the agreement (after consider- 9. Consider the need to make your company limited. ing the EMWA points for inclusion in freelance med- Some UK-based pharmaceutical companies and ical writers’ agreements or contracts) in an e-mail recruitment agencies require that persons who work for (check whether e-mails are legally binding in your them do so under the auspices of a limited company. country). If not, ask for brief confirmation by post. 10. Consider the need for establishing a presence on the 16. Whenever possible, only perform work after having a Internet. Buying a domain name is often worthwhile. (signed) agreement in place (this may, of course, be This is inexpensive and will avoid complications if you an e-mail). If a potential client invites you to attend a subsequently change your Internet Service Provider meeting before signing a contract, then make clear your (ISP) as you can retain your e-mail address. It will also expectations in terms of compensation for meeting allow you to use an e-mail address that relates to your attendance. This also applies to telephone conferences. business, rather than a generic name (e.g. 17. If you are unsure of the reliability of a company or btinternet.com). It will also provide web space if you organisation you will be working with, it is good decide you need a presence on the World Wide Web. practice to check this via your country’s listing of Alternatively you may find it easier to use a yahoo.com registered companies. In the UK consult the or mail.com address as you can change ISP without Companies House listing http://www.compa- altering your e-mail address. There may be limitations nieshouse.gov.uk/. In Germany most public listed on the size of files you can send or receive as attach- companies can be found at http://www.deutsche- ments, and so it is advisable to investigate all options. boerse.com or you can ask the local Industrie- und 11. Consider the need for opening a business bank Handelskammer for information. Also check compa- account. In the UK some banks charge for business ny websites to see how well-established the company accounts while others do not (e.g. The Abbey). A sep- is, for example, determine the number of products on arate account for business is a more efficient way of the market or in the pipeline and how the company is managing your affairs. In Germany costs for a current financed. >>>

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>>> Presenting freelance support for the freelance membership… Points for inclusion in freelance medical writing 6. State that the client will be responsible for checking agreements the contents of the prepared texts for errors and inac- The following points are suggested for inclusion in free- curacies, and will be responsible for the final sign-off lance medical writers’ agreements or contracts (henceforth of that text. The client must hold harmless and referred to as the agreement). The agreement may be initi- indemnify the writer against any liability except in ated by the medical writer, using the points listed. the case of intent or gross negligence on the writer’s Alternatively the points may be used as a checklist of items part. The client should also agree to hold harmless included in client-initiated agreements. and indemnify the writer regarding third party rights General in the execution of the agreement and the writer will 1. Detail all parties included in the agreement, the date not be held liable for any damage or loss whatsoever. of initiation, and services covered by the terms of the Copyright agreement. The agreement can be extended beyond 7. State that any information, inventions or discoveries this period by written agreement of both parties. State (whether patentable or not), product innovations, sug- that any interim alterations to the scope of agreed gestions, ideas and reports made or developed under work will be regarded as additional, must be made in this agreement shall be promptly disclosed to the writing, and that payment for this additional work client and shall remain their property. will need to be negotiated. State that the assignment 8. State that right to use the work developed under this will be considered completed on submission of the last planned piece of work, and that this is when the agreement will be transferred to the client after pay- final invoice will be submitted. ment of the entire cost of the agreement. 2. The agreement/contract must be signed and dated by Termination both parties (the place of signing is also needed in 9. State that either party can terminate the agreement at some countries). any time by giving 30 days’ written notice. However, Financial if this is not possible (e.g. through illness) then state that termination may be agreed immediately. Clients 3. Detail the agreed hourly rate, or absolute value of the might reasonably expect that under such circum- agreement, and when invoices will be issued. This stances a replacement writer is suggested. A clause may be monthly in arrears or on completion of agreed can be included that during the period of notice the milestones. Detail how many days the client has to writer will make reasonable efforts to find a substi- pay from the date of the invoice. Industry standard is tute writer who, to the best of his or her knowledge, 30 days. If your company is VAT registered, you may can fulfil the contract, but that no guarantee of this need to charge VAT. Charging of VAT should be can be given. investigated for your country. If your client is based abroad, the agreement may be VAT exempt. Clearly 10. State that upon completion of a project, all material specify if VAT will be charged or not. provided or developed as a result of the agreement 4. Be clear that payment for services is not dependent on will be destroyed or returned to the client and that, as publication, for example, in the case of preparation of a far as possible, all electronic materials will be deleted. manuscript. The writer should be compensated for the Confidentiality actual writing task and this should be independent of 11. During the term of the agreement and for ten years acceptance of the manuscript by the target publication. afterwards state that due care shall be exercised to Liability prevent unauthorised disclosure of confidential infor- 5. State that the services will be performed on a ‘best- mation. effort’ basis in accordance with the standard of care Dispute reasonably expected in the performance of such serv- 12. Depending on your location, state that this agreement ices. State that the client is responsible for providing shall be governed in accordance with your country’s sufficient information and materials for execution of law (and in some countries, e.g. France and Germany, the agreement in good time (stating dates, if possi- a ‘place of jurisdiction’ [meaning the name of a town] ble). The client must be available during the execu- has to be given). In the case of dispute, state that the tion of the agreement to answer questions. Any delays caused by unavailable data on the part of the parties will first attempt to resolve the dispute by client remain the responsibility of the client. State mutual consultation and agreement out of court. that the writer will inform the client in good time if he or she feels that agreed timelines can no longer be Sam Hamilton met because of late delivery, unexpected volume, or Sam Hamilton Medical Writing Services Limited Newcastle Upon Tyne, UK other reasons, and that new timelines (and possibly [email protected] higher remuneration) must be negotiated. http://www.samhamiltonmwservices.co.uk/

137 The Journal of the European Medical Writers Association TheWrite Stuff Vol. 16, No. 3, 2007

EMWA Freelance Business Survey 2007

by Alistair Reeves and Sam Hamilton

The previous and first EMWA Freelance Business Survey Type of freelancer and hours worked was conducted in 2003 on a paper questionnaire distributed 57/96 (59%) of respondents were full-time freelancers, at the Lisbon Freelance Forum and was subsequently sent 32/96 (33%) part-time freelancers, and 7/96 (7%) were in out by post and e-mail. It was an ambitious questionnaire full-time employment and doing freelance work. No defi- (first attempts at anything often are!), as any reader who nition of ‘full-time’ or ‘part-time’ was given; the respon- has consulted the results of the survey on the website will dents decided whether they were full-time or part-time. have seen. With much badgering and follow-up, we finally 52/95 (55%) respondents work 31 – >50 hours per week, received 63 completed questionnaires. presumably mostly full-timers, and 43/95 (45%) work For the 2007 survey, we moved into the 21st Century with 1–30 hours per week, presumably mostly part-timers a much simplified, web-based questionnaire on www.sur- (Table 1). veymonkey.com, following Kelly Goodwin’s example Table 1: Number of hours worked per week (N=95) with the EMWA survey for salaried medical writers. Our Hours per week Number of responses (%) survey was open from 4 March–13 July 2007, by which 1-10 10 (11) time, with advertising in TWS, on the website, and at the Vienna 2007 conference, 101 respondents had completed 11-20 7 (7) at least one question—a much better result than 2003. Most 21-30 26 (27) respondents completed most of the questions, but two 31-40 31 (33) respondents answered only one question each. 41-50 16 (17) >50 5 (5) This report on the 2007 survey includes some comparisons with the results of the 2003 survey. A document on the Sources of work website contains all results for both years where possible; Respondents were asked to indicate their sources of work it was not always appropriate because the content of some (totalling 100%) from the categories given in Table 2, of the questions differed. Also, the 2003 questionnaire was which shows the mean percentage of work obtained from addressed to individual freelancers and small businesses each source. with up to 7 employees (the latter accounted for 27% of the Table 2: Sources of freelance work (N=87) sample), whilst the 2007 survey was addressed only to individual freelancers, whether registered as a limited com- Source Mean % of work pany (or national equivalent) or not. The 2007 survey is Longstanding customers 49 now closed. Referrals from colleagues 22 CROs/agencies 21 Number of responses and countries Referrals from customers 10 By 13 July 2007, 101 responses had been received: 47 EMWA freelance directory 10 (47%) from the United Kingdom, 20 (20%) from Germany, Own advertising 8 6 (6%) from Switzerland, 4 (4%) from France, 3 (3%) from Other freelance directories 1 Spain, 2 each (2%) from India and The Netherlands, and 1 ‘Looking for a medical writer’ 1 each from Austria, Belgium, Canada, China, Denmark, Other 1 Eire, Italy, Portugal, Taiwan, Sweden, and the United States of America (6 respondents skipped the question). CRO=contract research organisation This pattern was similar to that of the 2003 survey. It is EMWA membership and website worth noting, however, that the mean percentage of work 85/99 (86%) respondents were EMWA members, and from the EMWA freelance directory increased from 5% in 48/99 (49%) had their own website. 2003 to 10% in 2007. >>>

The Journal of the European Medical Writers Association 138 Vol. 16, No. 3, 2007 TheWrite Stuff

>>> EMWA Freelance Business Survey 2007 Types of activity Hourly charges for medical writing and related activities Respondents were asked to indicate their types of activity All charges were to be given in euros as average hourly (totalling 100%) from the categories given in Table 3, rates for the activity in question. Charges entered in other which shows the mean percentages of each type of activity. currencies were converted to euros at the 13 July 2007 rate. Table 3: Types of freelance activity (N=84) An hourly rate of € 750 for all activities from one respon-

Type of activity Mean % of work dent was assumed to be € 75. Several respondents entered ranges: the midpoint was taken as the average value. Writing 67 Editing 18 The average hourly rates (mean ± standard deviation; Translation 11 median [range]) for the different activities are given in Consultancy work 6 Table 5, rounded to full figures.

Training events 6 Table 5: Average hourly rates

Quality control 6 Activitya Hourly rate (€) Proofreading 3 2007 2003b E-publishing 1 N mean ± SD median (range) N median (range) Other 3 Consultancy 26 105 ± 50 91 (29–250) 26 105 (20–>160) Medical writing 76 76 ± 23 75 (29–140) 55 80 (20–160) Again the pattern was similar to the 2003 survey, with writ- ing as the major activity, followed by editing and transla- Editing 52 71 ± 26 75 (29–140) 48 70 (20–150) tion. The mean percentage of work time spent writing Quality control 26 73 ± 31 65 (30–150) 21 75 (20–>160) increased from 57% in 2003 to 67% in 2007, and the mean Proofreading 34 69 ± 29 62 (25–140) 24 55 (20–150) time spent translating from 5 to 11%. SD=standard deviation a 3 respondents answered for E-publishing with hourly rates of € 65 (2) and 200 (1). b Mean ± SD was not calculated for 2003. Types of documentation Average hourly rates have not changed between 2003 and Respondents were asked to indicate the type of documen- 2007. The absence of a difference between the medians and tation they generally work on (totalling 100%) from the categories given in Table 4, which shows the mean percent- ranges for writing and editing may be because editing was ages of each type of document worked on. defined as ‘editing texts that need considerable rewriting’. The lower medians for consultancy and writing may have Table 4: Types of freelance activity (N=83) been influenced by the absence of small businesses from Type of documents Mean % of work the sample. Except for consultancy, there were no respons- Documents used for drug approval 41 es higher than € 150 per hour for any activity, and some of Scientific papers 35 us will be surprised that some colleagues can evidently Marketing materials 12 earn as much as this per hour on average. Some writers, Training, presentation and educational materials 6 however, are still obviously charging very low average Investigator brochures 5 rates (10/76 responses for writing and 13/52 for editing Product information, websites 4 were between € 29 and 49 per hour). Perhaps this survey Text books, SOPs 3 will encourage them that they can reasonably charge more. Consultancy documentation 1 19 respondents entered charges for training (Table 6, User manuals for devices 0 rounded to full figures). Other 6 Table 6: Charges for training SOP=standard operating procedure Activitya Hourly rate (€) As in 2003, the mean percentage of time spent on docu- 2007 2003b ments used for drug approval and journal articles for the med- ical and scientific press were greatest. The mean percentage of N mean ± SD median (range) N median (range) time spent on journal articles increased from 24% in 2003 to Whole day 19 815 ± 406 1000 (400–2300) 16 955 (850–>1150) 35% in 2007. The absence of small businesses from the 2007 Half day 15 510 ± 238 475 (200–1000) 14 517 (475–775) sample may be partly responsible for this (this is based solely Hourly 7 107 ± 62 100 (46–200) 8 Not calculated (40–190) on the anecdotal observation [conversations at EMWA meet- Preparation 8 84 ± 34 84 (48–150) 3 Not calculated ings] that freelancers often seem to be approached by individ- SD=standard deviation uals to write or edit journal articles as they are expected to be a 2007 charges of € 75 for a half day and €150 for a whole day entered by one respondent were not included as these were assumed to be an error, because the same respondent gave an hourly rate cheaper, and it is often not worth small [and indeed larger] for training of € 100. businesses taking on this type of job.). b Mean ± SD was not calculated for 2003.

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EMWA Freelance Business Survey 2007

No substantial shifts in charges for half-day or whole-day The results were similar to those in 2003: about a third of training events were seen between 2003 and 2007. those who work for pharmaceutical companies charge Because we asked for average charges, we also asked them more than their average rate, and about 40–50% of respondents to tell us if they had different charges for dif- those who work for private people, colleagues, higher edu- ferent client groups (Table 7). cation establishments and physicians charge them lower rates than average. Most respondents who work for agen- Table 7: Charges for different client groups cies, CROs and government organisations (about 80–90%) Client groupa No clients N Lower Same Higher charge their average rates. Pharmaceutical companies 11% (8) 64 2% 64% 34% Thanks to Alison McIntosh for checking all the numbers. Agencies 26% (19) 55 7% 89% 4% We thank all those who took part in the survey. CROs 38% (28) 45 2% 92% 6% Private persons 61% (44) 44 54% 46% 0% Alistair Reeves Colleagues 43% (31) 41 49% 51% 0% Ascribe Medical Writing and Translation Higher education establishments 59% (45) 31 48% 52% 0% Wiesbaden, Germany [email protected] Physicians (hospital or practice) 60% (42) 28 39% 61% 0% http://www.ascribe.de Government organizations 66% (46) 24 17% 83% 0% Sam Hamilton CRO=contract research organisation a Each row should be read as follows: Pharmaceutical companies – 72 respondents answered the Sam Hamilton Medical Writing Services Limited question: 8+64 = 72; 8/72 (11%) do not work for pharmaceutical companies; of the 64 who work Newcastle Upon Tyne, UK for pharmaceutical companies, 2% charge lower than their average hourly rate, 64% charge their [email protected] average hourly rate, and 34% charge higher than their average hourly rate. http://www.samhamiltonmwservices.co.uk/

Freelance The noun ‘freelance’ was first coined by Sir Walter Scott in the 19th century and referred to a medieval mercenary soldier. Now the expression means a self-employed per- son offering their services where needed, not under con- tract to any single employer (source http://www.all- words.com where its translation into various languages can also be found).

Articles about medical writing in Science Magazine Anyone thinking of a career in medical writing might be interested in a series of articles in Sciencecareers of Science Magazine. These can be found on the website http://sciencecareers.sciencemag.org/career_development/ previous_issues/articles/ by adding the following after the last slash 2007_06_22/caredit_a0700088/(parent)/104 0980/careers_in_medical_writing_opening_doors_feature_ EMWA’s 17th Annual Spring index/(parent)/104 3570/starting_a_career_in_science_writing/ Conference 2008 (parent)/104 An important date to note for 2008’s diary is the EMWA Annual Spring Conference, which will be held from 29th Although these articles relate to the US much of what April to 3rd May 2008 in Barcelona, Spain, at the Hotel Rey they say is relevant to European medical writers too. Juan Carlos 1 (http://www.hrjuancarlos.com/en/index.html).

Thanks to Raquel Billions A full announcement will be made in the December ([email protected]) for these sites. 2007 issue of TWS.

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A continuing personal account of my first year as a freelance medical writer

by Sam Hamilton

As I progress through my first year in business as a free- arranged for her to have a few days with her grandparents lance medical writer, I invite you to share my experiences as she was not ill at all, just itchy! This enabled me to over the last quarter. In previous issues of The Write Stuff maintain momentum during that crucial period between (TWS), you heard about my journey to freelance medical statistical output becoming available and the draft report writing and my first six months in business. The next three deadline. The output at that stage was based on draft data. months have required hard work and long hours as con- My experienced client was entirely pragmatic in their tracts have come to fruition. In delivering several high approach to reporting this ‘large’ study which comprised quality documents, I have established relationships with a 20 secondary efficacy variables, and for which we both number of clients which I hope to cement over the coming knew the CSR would eventually turn out to be voluminous. years. Read how spring and early summer turned out as the I received draft output and, consequently, a head start with business developed apace. reporting. When the final output eventually arrived in late April, changes to draft data were highlighted, so I simply Months 6 to 9 revised the relevant pre-written sections. April 2007 I made minor revisions to the By early April, I heard back from Helen in the US. A fel- I scheduled report for which review of low freelance medical writer and close personal friend, she meticulously to the efficacy section had had been invited to bid for the writing of a programme of enable a degree of stalled in January. The safety early phase protocols for a major pharmaceutical company. data continued to be unavail- She had asked for my counsel during the bidding process harmony between able, so the report still could and we knew we would be working together for the next 18 work and family not be closed out. months to 2 years in the event of a win. We were both life. It actually We enjoyed some free time delighted and excited to hear that the bid had been success- worked pretty well, and even managed a few ful. Helen concentrated her efforts on widening her pool of considering my days away over the Easter US writers, and I firmed up arrangements with the smaller daughter had holidays, walking in the UK-based writing team which I would be running. We beautiful Lake District in the began to investigate setting different ideas… North West of England. up contracts which would be legally acceptable on both Enquiries come up In late April, I attended a networking event for new mem- sides of the Atlantic and regularly and new bers of the Healthcare Network North East England options for the exchange of business is often (www.hcnetnee.com), a local organisation which works currency with minimal asso- just around the with companies, including those involved in clinical ciated costs. research, to increase sales and market opportunity through corner, though one networking. I was the only new member present in my Several writing activities might not realise it field, and most other participants appeared to make compo- were already underway in at the time. nents for use in equipment designed to improve the quality early April, including draft of life for physically incapacitated patients. As a result, net- reporting on as large a clini- working opportunities were a touch thin on the ground for cal study report (CSR) as I had tackled in 9 years, and me, so I simply enjoyed the lunch, participated as best I updating client comments on a partly completed CSR could and learned a little about an area I knew nothing which had been delayed from January. about previously. The children had two weeks of Easter holidays looming, so I wrote a Standard Operating Procedure (SOP) for a with this in mind, I scheduled meticulously to enable a University-based group overseeing investigator-led clini- degree of harmony between work and family life. It actual- cal research activities in the region. ly worked pretty well, considering my daughter had differ- ent ideas, caught chicken pox and was excluded from A large contract I had been negotiating for the past 3 school for the last week of term, extending her holiday months eventually fell through, due to lack of funding. I somewhat! So as to avoid a rapid descent into chaos, I accepted and moved on from this more readily than I had

141 The Journal of the European Medical Writers Association TheWrite Stuff Vol. 16, No. 3, 2007

A continuing personal account... expected, which told me that I had finally begun to think in hand, to locate my family who were camping deep in the like a seasoned freelancer. I was starting to realise that Cumbrian countryside. We spent 4 chilled-out days together enquiries come up regularly and new business is often just before I had to leave them early to resume work. around the corner, though one might not realise it at the time. June 2007 May 2007 Final output for the smaller CSR arrived a few days ahead May was an extremely busy month for me. I completed the of client comments on the large CSR. I worked long hours shell of a CSR I had begun preparing in February, as the with the family still away. Helen quality controlled the last of the component documents arrived. Helen was con- small report and I ultimately exceeded both reporting dead- tracted to perform quality control (QC) review of the full lines by 3 days. It would be fair to say that by mid-June, I report and she did this in two stages, the first being QC of felt very much in need of a change of pace. My client was the shell. I was delighted to see that we worked very well happy with my efforts on the large report and anticipated together as a team and she worked to the same standard as further need of my services in future. The smaller report’s I expected of myself. A promising partnership was under- comments were delayed, possibly until August—a mutual- way! The completed shell was now ready for the results ly agreeable decision. expected later in the month. I caught up on outstanding actions from the Vienna confer- I continued to update and ence, with the generous help of 4 fellow freelancers, Alistair revise the large CSR with I worked long hours Reeves, Helen Kulesza, Elaine O’Prey and Linda Liem. final data. During this stage with the family still I also set up a currency trading account to facilitate afford- of reporting, things became a away… and I able currency exchange between Helen and myself. In set- little more complicated for a ultimately exceeded ting up a XETrade account (https://www.xe.com/fx/), I was number of reasons. The client able to pay Helen for her QC services direct in dollars elec- required my report to stylisti- both reporting tronically transferred to her US account whilst incurring no cally match a report being deadlines by 3 days. currency exchange charges whatsoever. Neat! written internally, concurrent to mine. Myself and my fel- I prepared PowerPoint presentations for two lectures I was low writer shared sections of our reports as we completed due to give at the University in July. I was grateful to them, to ensure some degree of match. However, timing Wendy Kingdom, a seasoned EMWA lecturer and fellow was not perfect, so we knew that some sections would freelancer, who was generous with her time and advice in require revision very late in the reporting process. Revised relation to preparation of one of the lectures. primary analysis coupled with additional analyses in a sub- As previously, a couple of minor pieces of work cropped group of ‘interesting’ patients added to my workload. up, were executed and closed out, all of which brought However, I submitted the draft report on time in mid-May. June to a highly satisfactory conclusion. The summer The client very reasonably agreed to compensate me for loomed and I looked forward to a family holiday in the US the changes of scope from the originally contracted task. and a slower pace of life, at least for a couple of months. My accountant, Lynne, forwarded an unexpected incentive I will update you on my fourth quarter in business during payment as a result of her having registered my taxation my first year of trading, so look out for my final article in details online. It was certainly a sum better in the business’ the next issue of TWS. coffers than the government’s, in my opinion!

I attended 3 days of the EMWA Vienna conference. I Sam Hamilton arrived somewhat late for the Gala Dinner on the Sam Hamilton Medical Writing Services Limited Newcastle Upon Tyne, UK Wednesday evening due to my late incoming flight—per- [email protected] haps a taste of things to come… I attended the final two www.samhamiltonmwservices.co.uk courses which would hopefully lead to my foundation accreditation, joint-chaired the Freelance Forum with Alistair Reeves and hosted a lunch discussion table. I met EMWA is currently developing a freelance e-mail user many old friends, made some new friends and generally group so that the freelance membership may raise issues had a great time. It was a real antidote to the unrelenting for debate between meetings. More information on the pace of the previous couple of months. However, my return list will be available shortly, so watch the website. In home was not quite as straightforward as it should have addition, due to popular demand, the Freelance Forum been, and included a cancelled connecting flight from Paris will now take place at both the Spring and Autumn con- to Newcastle on Friday afternoon, an enforced overnight ferences from November 2007. We would welcome your stay in Paris and purchase of another flight to get me home feedback on our endeavours to date, so do please join us before the whole Bank Holiday weekend expired. Having in Basle (Friday 2 November 2007, 1730-1830) and returned home a day late, I then drove determinedly, map Barcelona and have your say.

The Journal of the European Medical Writers Association 142 TheWrite Stuff

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Do we need proof? Vol 16, No. 3, 2007 Richard Clark Cross-over trials: Painful lessons 99

Jack Aslanian Reflections on terminology: Not ‘alternative’ medicine but integrative medicine 101

Wendy Kingdom Breaking news 104

Madeline Frame Making the most of clinical trials publication 106

Cathy Holding What makes science news? 108

Geoff Hart Successful cross-cultural communication requires us to test our assumptions 111

Jenny Fanstone Transparency in medical writing: Medical writers leading the way 114

Karen Shashok Word 2007—rejected with an invitation to revise and resubmit 115

Alistair Reeves Still more myths about English (5) 118

Alistair Reeves Multiple problems: Different or more of the same? 122

Alistair Reeves 4-letter words and others 124

Freelance Section Sam Hamilton Presenting freelance support for the freelance membership… 135

Alistair Reeves and Sam Hamilton EMWA Freelance Business Survey 2007 138

Sam Hamilton A continuing personal account of my first year as a freelance medical writer 141

Regular features From the Editor’s desk 95 Message from the President 97 In the bookstores 126 Webscout 130 Journal watch 131 Only my opinion 133

The Journal of the European Medical Writers Association